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The  Stomach  and  CEsophagus 


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THE  STOMACH   AND 
OESOPHAGUS 


A    Radiographic    Study 


BY 

ALFRED  E.  BARCLAY,  M.A.,  M.D.,  B.C.  (Cantab.). 
M.R.C.S.,   L.R.C.P. 

Medical  Officer  to  the  x-Ray  and  Electrical  Departments  of  the 
Manchester  Royal  Infirmary  ; 
Late  Clinical  Assistant,  Electrical  Department,  London  Hospital. 
Council  of  Electro-Therapeutic  Section  of  the  Royal  Society  of  Med' 


THE  MACMILLAN  COMPANY 
64-66,  FIFTH  ATE  XL  E 
NEW  YORK 

1913 


14-  abrty 


3  a  a 


PREFACE 

r 

This  little  volume  is,  in  essence,  a  thesis.*  Sir  Clifford 
Allbutt,  Sir  William  Osier,  Dr.  R.  Hutchison,  and 
others  who  read  it  were  kind  enough  to  suggest  that  it 
was  worthy  of  publication,  and  these  pages  are  re-printed 
with  some  alterations  and  additions  from  the  Medical 
Chronicle  by  the  courtesy  of  the  Editor,  Dr.  E  .  M. 
Brockbank.  The  chief  alteration  is  the  inclusion  of 
Chapter  VIII  on  the  ./Etiology  of  Gastric  Ulcer,  which 
was  conceived  and  written  after  correcting  the  rest  of 
the  proofs  of  this  volume.  To  Dr.  J.  Gow  I  am  indebted 
for  the  Index,  and  to  Prof.  Dr.  Gocht  for  the  Bibliography. 

March,   1913. 

*  Submitted  for  the  degree  of  M.D.,  at  Cambridge,  in  April,  1912,  and 
placed  prox.  access.  Horton  Smith  prize. 


CONTENTS. 

PAGl 

Chapter     I.     INTRODUCTION i 

Chapter  n.    Technique 5 

Fundamental  principles,  method*,  of  examination, 
protection  of  the  patient,  protection  of  the  observer, 
position  of  the  patient,  preparation  of  the  patient, 
foods  used,  special  methods. 

Chapter  III.     Tin.;   Diagnosis  <>v  Ai  it.c  tions  or  THE  CE80PHAGU8  '.■, 
The  causes  of  oesophageal  obstruction,  the  stages  of 
oesophageal  obstruction. 

Chapter  IV.     Tin.;  NORMAL   STOMACH 22 

Position,  shape,  capacity,  tonic  action,  peristalsis, 
control  of  the  pylonis,  control  of  peristalsis  and  tonic 
action,  notes  on  cases  operated  on. 

Chapter    V.    The  PATHOLOGICAL  Stomach 30 

Atony 3° 

Pyloric  Obstruction                  33 

Notes  on  Casks 36 

Hypersecretion 37 

Notes  on  Cases  of  Ulcers  of  Pyloric  Regions    -  37 

Chapter  VI.     Gastric  Ulcer  and  Hour-glass  Stomach        -        -  39 

Ulcer  of  the  Fundus        ------  39 

Ulcers  of  the  Pylorus      ------  39 

Ulcers  of  the  Body  of  the  Stomach     -       -       -  40 

Notes  on  Cases -       -  43 

Carcinoma  of  the  Stomach 46 

Notes  on  Cases  --------  48 

Aerophagy   ---------  49 

Post  Operative  Examinations  -----  50 

Incidence  of  Lesions  of  the  Stomach    -        -        -  53 

Chapter  VII.    Small  Intestine  -        -        - 54 

Duodenal  Ulcer 54 

Notes  on  Cases  --------  55 

Chapter  VIII.  The  ^Etiology  of  Gastric  Ulcer    -        -        -        -62 

Chapter  IX.     Conclusions         --------  73 

Chapter   X.    Tabulation  of  Cases   -------  77 

Class  1.     Normal        -                                 79 

Class  2.    Duodenal  Irritation       ------  81 

Class  3.    Ulcers  of  Pyloric  Region    -----  84 

Class  4.    Ulceration  of  the  Body  of  the  Stomach    -        -  85 

Class  5.    Carcinoma  of  the  Stomach    -        -        -        -        -  SS 

Class  6.    Pyloric  Obstruction      ------  89 

Class  7.    Adhesions         --------  05 

Class  8.    Post  Operative  Examinations       -        -        -        -  96 

Bibliography       -----------99 

Index 123 


FIG. 

i.  Diagram. 
2- 

3- 

4- 

5- 
6. 


9- 

10. 


21. 


Radiogram. 

>> 
Diagram. 


ii — 14. 


15- 


16. 

>> 

17- 

>> 

iS. 

Radiogram 

19. 

m 

20. 

j» 

22. 

>> 

23- 

Diagram  of 

24. 

Radiogram 

25- 

Diagram  of 

26. 

Radiogram 

27. 

)  y 

28. 

Diagram  of 

29. 

Radiogram 

LIST    OF  ILLUSTRATIONS. 

FACING   PAGE 

Course  of  the  oesophagus ic 

Slight  bulging  of  aortic  arch        -        -        -        -  15 

Large  aneurism  causing  oesophageal  obstruction  15 

Growth    in  posterior   mediastinum   causing   ob- 
struction     --------  i^ 

(Esophageal  obstruction 15 

(Esophageal  obstruction  at  cardiac  orifice   -        -  15 

(Esophageal  obstruction  due  to  small  ulcer        -  19 

Cardiospasm 19 

Air  in  the  fundus  of  the  empty  stomach      -        -  23 

Air  in  the  fundus  of  a  stomach  that  already  con- 
tained food          -------  23 

Illustrating   the  manner   in   which   the   normal 

stomach  accommodates  the  food       -        -        -  23 

Bismuth   food  entering  a  stomach  that  already- 
con  tains  food 31 

Bismuth  food  entering  an  empty  atonic  stomach  31 

Bismuth   food  entering  an  atonic  stomach  that 

already  contains  food        -        -        -        -        -  31 

of  an  extremely  atonic  stomach  (pyloric  obstruc- 
tion)       32 

of  an  atonic  stomach  showing  the  rugae         -        -  32 

of  an  atonic  stomach  with  retained  food.     Type  1 

of  chronic  pyloric  obstruction  -  -  -  -  35 
of  an  atonic  stomach  with  retained  food.     Type  2 

of  chronic  pyloric  obstruction  -        -        -        -  35 

of  typical  upper  sac  of  an  hour-glass  stomach        -  40 

hour-glass  stomach  with  atony  -  -  -  -  40 
of  an  hour-glass  stomach  with  small  penetrating 

ulcer   (Haudek) -  40 

hour-glass  stomach  with  atony        -        -        -        -  40 

of  an  hour-glass  stomach  -----  43 
of  stomach  with  chronic  penetrating  ulcer  giving 

rise  to  no  symptoms 43 

a  case  of  carcinoma  of  the  stomach  -  -  -  47 
of  a  case  of  carcinoma  of  the  stomach      -        -        "47 


CHAPTER  I. 

INTRODUCTION. 

The  diagnosis  of  gastric  and  intra-abdominal  lesions  is 
perhaps  the  most   intricate  and  difficult  branch  of  medicine, 

and  even  in  experienced  hands  the  condition  found  post- 
mortem or  on  the  operating  table  is  often  very  far  different 
from  that  which  was  suspected  from  a  full  consideration  of 
all  the  various  signs,  symptoms,  and  clinical  tests  available. 
Therefore  the  importance  of  any  new  method  that  will  be  of 
assistance  in  the  diagnosis  of  these  cases  cannot  be  over- 
estimated. The  application  of  the  A'-rays  in  the  diagnosis  of 
these  conditions  has  been  productive  of  excellent  results  in 
this  respect. 

In  the  early  days  of  #-ray  diagnosis  one  expected  that  by 
merely  seeing  the  shape  of  the  shadow  of  the  food  in  the 
stomach  a  diagnosis  could  at  once  be  formed.  It  was  only 
after  a  number  of  failures  that  one  was  driven  to  the  obvious 
conclusion  that  a  thorough  study  of  the  normal  stomach  was 
essential.  A  better  knowledge  of  the  limitations  of  the 
method  must  be  arrived  at  before  undertaking  the  examination 
of  the  pathological  cases.  The  difficulties  of  interpreting  the 
shadows  cast  by  the  bismuth  meal  in  the  stomach  are  great ; 
for  not  only  is  the  organ  absolutely  different  in  shape  during 
life  from  the  pictures  one  would  expect  from  the  study  of 
anatomy,  but  also  even  slight  alterations  in  tonic  action  will 
produce  a  picture  that  appears  to  be  very  different.  Again, 
the  conditions  found  at  operation  were  often  quite  the  reverse 
of  what  one  expected  from  the  ,^-ray  examination.  For 
instance  one  reported,  after  .r-ray  examination,  a  stomach  of 
normal  size,  and  the  surgeon  at  the  operation  found  a  large 
flaccid  sac  and  vice  versa.  And  in  the  study  of  the  normal 
great  difficulty  was  experienced,  for  it  was  found  that  even  in 
healthy  subjects  the  stomach  apparently  varied  to  an  amazing 
extent,  not  onlv  in  shape  and  position  but  also  in  the  manner 
B 


2  Gastric  and  oesophageal  affections 

in  which  the  muscular  walls  appeared  to  act.  Another 
difficulty  was  presented  by  the  fact  that  the  pictures  seen  when 
the  patient  was  in  the  upright  position  differed  completely 
from  those  obtained  when  the  patient  was  examined  lying  on 
the  couch.  One  was  also  occasionally  confronted  with  such 
phenomena  as  that  of  a  healthy  subject  whose  stomach  seemed 
to  conform  to  all  one's  ideas  of  what  a  healthy  organ  should 
be  on  one  examination,  while  on  the  following  day  a  picture 
that  seemed  to  bear  little  or  no  resemblance  to  the  previous 
one  was  seen. 

Up  till  the  last  two  years  it  was  often  a  matter  of  specula- 
tion as  to  whether  one  would  be  able  to  obtain  #-rays  of 
sufficient  power  to  penetrate  the  abdomen  of  any  but  the 
thinnest  patients,  and  in  a  great  number  of  the  early  cases  one 
had  the  utmost  difficulty  in  obtaining  even  a  rapid  glance  of 
the  shadow  before  the  force  of  the  currents  used  wrecked  the 
.r-ray  tube.  It  wras  very  seldom  that  one  could  study  the  pars 
pylorica.  Moreover,  it  was  only  when  the  apparatus  was 
working  at  its  most  efficient  pitch,  and  when  the  #-ray  tube 
happened  to  be  in  exactly  the  right  condition,  that  a  radio- 
graph could  be  taken,  and  even  then  the  exposure  had  to  be  of 
such  lengthy  duration  that  all  detail  was  lost  owing  to  the 
peristaltic  movements  of  the  walls. 

During  the  last  two  years,  however,  one  has  been  able  to 
rely  upon  obtaining  a  satisfactory  screen  examination  in 
nearly  all  cases,  and  it  is  only  in  the  study  of  the  pars  pylorica 
that  one  could  often  have  wished  for  greater  clearness  in  the 
screen  image.  Radiographs  have  often  been  taken  but  they 
have  seldom,  if  ever,  revealed  greater  detail  than  could  be 
made  out  by  the  screen  examination,  owing  to  movements 
during  the  lengthy  exposures  that  were  necessary.  In  the 
last  few  months,  however,  the  introduction  of  the  intensifying 
screen  has  reduced  the  exposures  to  a  matter  of  a  second  or  so, 
with  the  result  that  whenever  it  is  not  possible  to  see  exactly 
what  is  going  on,  a  picture  may  be  taken  that  will  be  of  con- 
siderable assistance  in  the  diagnosis. 

Such  are  some  of  the  difficulties  which  have  beset  the 
earlier   stages   of  this  work,    but     apart    from    the   technical 


Introduction  3 

difficulties  one  conclusion  stands  out  with  great  clearness; 
no  one  picture  can  be  taken  to  represenl  tin-  normal  stomach, 
and  no  detailed  study  of  a  .small  number  "I  normal  subjects 
can  be  of  great  value  in  itself;  it  is  only  by  the  consideration 
of  a  very  large  number  of  cases  thai  a  clear  conception  of  the 
possible  variations  of  the  normal  stomach  can  be  obtained,  and 
it  is  only  after  this  knowledge  has  been  obtained  that  the 
value  of  the  .c-ray  method  of  examination  in  the  diagnosis  of 
pathological  conditions  of  the  stomach  becomes  of  value. 

I  have  been  much  impressed  by  the  fact  that  frequently  (/ 
the  symptoms  of  the  severity  in  relation  to  extent  of  lesion 
appear  to  bear  very  little  relation  to  the  extent  of  the  disease 
found  at  the  operation — the  nervous  condition  of  the  patient 
apparently  being  responsible  for  the  accentuation  of  subjective 
sensations  that  in  a  phlegmatic  subject  would  be  accounted 
of  little  moment.  In  this  respect  the  contrast  beween  hospital 
and  private  patients  has  been  very  marked. 

The  whole  alimentary  canal,  but  especially  the  stomach, 
is  an  exceedingly  sensitive  muscular  organ,  and  spasmodic 
conditions  have  been  found  (and  during  the  last  two  years 
recognised)  in  a  large  proportion  of  pathological  cases.  These 
spasmodic  contractions  have  been  a  source  of  much  trouble  in 
diagnosis,  and  it  was  not  until  I  realised  that  they  entered 
into  and  complicated  almost  every  active  lesion  involving  the 
mucous  membrane  that  I  appreciated  their  importance,  not 
only  in  complicating  the  diagnosis  but  in  interfering  with  the 
gastric  functions,  in  man}'  cases  causing  complete  functional 
biloculations  of  which  no  suggestion  was  found  at  the 
operation.  It  was  found  that  the  extent  and  severity  of  the 
spasmodic  element  of  organic  lesions  did  not  bear  any 
relation  to  the  size  or  appearance  of  the  ulcerations,  and  the 
suggestion  is  that  theseveritv  of  the  spasm  depends  rather  on 
the  irritability  of  the  ulcer  than  upon  any  other  factor. 

In  this  thesis,  therefore,  I  propose  to  deal  chiefly  with  the 
explanation  of  the  various  difficulties  met  with  in  the  normal 
and  pathological  cases  examined,  and  to  lay  down  the  signs 
on  which  the  diagnosis  of  morbid  conditions  may  be  given. 
Full  use  has  been  made  in  everv  case  of  the  clinical  history 


4  Gastric  and  oesophageal  affections 

and  such  other  evidence  as  was  available  before  giving  a 
diagnosis,  and  although  one  is  so  thoroughly  convinced  of 
the  enormous  value  of  this  method — especially  in  indicating 
those  cases  that  are  suitable  for  operation — one  must  urge  that 
the  #-ray  method  is  only  one  of  the  means  at  our  disposal,  and 
that  if  we  do  not  use  all  the  evidence  available,  the  use  of  this 
method  by  itself  will  lead  to  mistakes  in  diagnosis,  and  we 
will  be  doing  less  than  justice  not  only  to  the  means  of 
diagnosis  at  our  disposal  but  also  to  the  patient. 

I  am  quite  conscious  of  having  received  many  suggestions 
from  writers  on  the  subject  but,  as  will  be  seen,  the  thesis  is 
based  almost  exclusively  on  my  own  examinations.  It  is  of 
considerable  size,  and  I  have  therefore  omitted  the  historical 
outline  and  summary  of  the  work  done  by  others  in  this  branch 
of  medicine. 

It  was  Cannon  who  first  initiated  the  study  of  the  intestinal 
movements  in  dogs  and  cats  by  means  of  giving  large  doses 
of  bismuth,  but  as  applied  to  the  examination  of  the  human 
alimentary  canal,  Rieder  of  Munich  was  the  pioneer,  for  it  was 
he  who  first  demonstrated  that  the  large  doses  necessary  for 
these  examinations  were  quite  harmless,  although  previously 
Roux  and  Balthayan  had  attempted  diagnosis  by  means  of 

5  drachm  doses.  Many  observers  have  written  on  the  subject 
but  the  following  names  stand  out  most  prominently  :  — 
Holzknecht  and  Jonas  of  Vienna,  Jolasse,  Leven  and  Barrett, 
Haudek,  Groedel,  Rosenthal,  Kaestle  and  Hertz. 

My  own  work  on  this  subject  commenced  in  1906,  and 
since  then  I  have  availed  myself  of  every  opportunity  of 
examining  both  normal  and  abnormal  subjects.  I  have  notes 
of  nearly  900  patients  examined*  and  there  are  many  others 
of  whom  I  have  no  records,  either  owing  to  the  rush  of  hospital 
work,  or,  as  in  many  of  the  normal  cases,  because  nothing 
worthy  of  note  was  found  at  the  examination.  As  a  routine 
practice,  I  see  each  patient  two  or  three  times  during  the  first 
hour  after  the  meal  has  been  taken  and  then  re-examine  after 
24  hours,  so  that  the  actual  number  of  examinations  must  be 
very  large. + 

*  Up  to  December,  1912,  1,280  cases  had  been  examined.  A  proportion  of 
these  were  examined  in  conjunction  with  my  partner,  Dr.  Bythell. 

t  The  double  bismuth  meal  saves  time,  but  I  do  not  use  it  as  there  is  less 
likelihood  of  overlooking  abnormalities,  especially  of  the  small  intestine,  when 
one  follows  the  whole  process  from  the  beginning. 


CHAPTER  II. 

TECHNIQUE. 

i.  Fundamental  Principles. 

The  aj-rays  penetrate  all  substances  to  a  greater  or  lesser 

extent,  the  resistance  llinl  is  offered  lo  their  passage  being 
approximately  in  direct  proportion  to  the  specitu  gravity. 
The  walls  of  the  alimentary  canal  do  not  differ  from  the  rest 
of  the  abdominal  contents  in  this  respect,  and  consequently 
they  give  no  distinctive  shadow  on  the  fluorescent  screen  or 
radiogram. 

The  method  therefore  depends  on  filling  the  cavities  with 
some  substance  that  differs  as  widely  as  possible  in  density 
from  that  of  the  tissue  structures,  i.e.,  something  very  heavy, 
such  as  a  bismuth  salt,  or  by  inflating  them  with  air  or  gas. 
In  the  former  case  the  contents  obstruct  the  rays  and  therefore 
a  dark  shadow  is  thrown  upon  the  fluorescent  screen,  whereas 
in  the  latter,  the  air  allows  the  rays  to  pass  more  freely  and 
therefore  the  screen  is  more  brilliantly  illuminated.  This 
latter  method  is,  however,  of  very  limited  value. 

2.  Methods  of  Examination. 

The  examination  should  be  undertaken  with  the  patient 
standing  with  his  abdomen  pressed  against  the  screen,  and 
the  passage  of  the  first  mouthfuls  should  always  be  carefully 
observed  from  the  cardiac  orifice  to  the  lowest  point.  I  have 
found  that  examinations  made  in  the  upright  position  yield 
infinitely  more  information  than  those  conducted  with  the 
patient  lying  down,  and  as  these  latter  examinations  give  a 
different  picture  which  may  be  very  misleading,  I  have 
purposely  omitted  any  description  of  them  in  order  to  avoid 
confusion. 

Radiographs  are  of  comparatively  little  use  except  for 
demonstration  purposes,  as  they  represent  the  picture  at 
one  particular  moment  only,  and  give  little  indication  as 
to   how   the  stomach   receives   the   food,   etc.       Radiographs 


6  Gastric  and  oesophageal  affections 

are  therefore  expensive,  and  in  many  cases  unnecessary 
luxuries  except  for  demonstration  purposes,  but  a  good 
radiogram  of  the  pars  pylorica  will  reveal  more  detail  than 
can  be  made  out  on  the  screen.  It  must  be  understood  that 
the  shadow  represents  only  such  of  the  contents  as  contain 
bismuth,  and  will  therefore  give  the  outline  of  the  cavity  only 
in  so  far  as  it  is  filled  by  this  food.  Consequently,  where  the 
tone  is  good  and  the  organ  contracts  upon  its  contents,  the 
bismuth  shadow  represents  the  true  shape  of  the  cavity, 
except  in  the  upper  part  (which  usually  contains  some  air, 
showing  as  a  light  area  beneath  the  left  dome  of  the 
diaphragm),  but  when  the  tone  is  defective  all  the  food  falls 
to  the  lowest  part,  and  it  is  only  this  portion  of  the  stomach 
that  is  outlined. 

3.  Protection  of  the  Patient. 

It  is  the  soft  rays,  the  ones  which  are  easily  stopped  and 
are  therefore  useless  for  this  type  of  examination,  that  produce 
.z-ray  dermatitis.  For  this  reason  the  patients  have  worn  a 
dressing-gown  or  other  garment,  and  in  practice  this  has  been 
found  quite  sufficient  protection,  as  not  a  single  case  of 
reddening  of  the  skin  has  been  noted,  although  many  of  the 
examinations — especially  for  demonstration  purposes — have 
been  very  prolonged.  Moreover,  repeated  examinations  have 
been  necessary  in  practically  every  case,  some  of  the  early 
ones  being  examined  as  many  as  eleven  times. 

4.  Protection  of  the  Observer. 

From  the  outset — in  1906 — it  has  been  evident  that  a  radio- 
graph of  the  stomach  contents,  no  matter  how  perfect,  could 
be  of  little  value  in  diagnosis,  just  as  a  photograph  would  be 
useless  in  depicting  an  ataxic  gait.  Therefore  examinations 
have  invariably  been  conducted  by  means  of  the  fluorescent 
screen,  and  this  has  necessarily  involved  a  great  deal  of  expo- 
sure to  the  rays  on  the  part  of  the  observer.  Great  difficulty 
has  been  experienced  in  devising  apparatus  for  self-protection 
that  would  yet  allow  of  easy  manipulation  of  the  patient. 
When  examining  with  the  subject  lying  on  a  couch  there  was 
little  difficulty,  as  one  was  not  in  the  direct  path  of  the  rays, 


Technique  7 

but  for  examination  in  the  upright  position  the  observer  is 
necessarily  in  front  of  the  lube      A  protective  diaphragm  ••'.••! 

therefore    m.'ide  by    the   hospital    staff   of   enrpenlers,    and   the 

quantity  of  rays  that  now  penetrates  is  infinitesimal. 

At  all  times  #- ray  proof  gloves  and  apron  have  been  v.orn 
and  no  dermatitis  has  been   sustained.      In    the   early   <\ 
before  the  fluorescent  screen   was  covered  with   «-ray    proof 
glass,  irritation  of  the  eyes  was  of  frequent  oecurrenre,  but  no 
permanent  ill-effects  have  resulted. 

During  periods  of  heavy  work,  before  the  operator 
efficiently  protected,  it  was  found  that  excessive  weariness  and 
mental  inertia  were  the  immediate  result  of  a  series  of  screen 
examinations,  but  since  the  addition  of  the  protective 
diaphragm,  already  referred  to,  this  effect  has  not  been  noted 
to  the  same  extent.  The  only  ill-results  now  encountered, 
even  on  the  busiest  days,  being  slight  weariness  and  headache, 
which  are  probably  not  due  to  #-rays  but  to  working  in  a  dark 
unventilated  room  in  which  the  air  is  in  a  partially  ionised 
condition.  (Recently  a  ventilating  fan  has  been  placed  in  the 
wall,  and  now  there  is  apparently  no  undue  weariness  even 
after  the  busiest  morning's  work.) 

5.  Position  of  the  Patient. 

(a)  In  gastric  cases.  It  was  at  once  apparent  that  posture 
had  an  extraordinary  effect  on  the  gastric  contents,  and  it 
became  a  matter  of  choice  whether  to  examine  the  patient 
standing  or  lying  down,  as  the  limitations  of  time  prevented 
a  routine  use  of  both  positions.  In  many  cases,  however, 
both  were  employed,  but  the  horizontal  position  practically 
never  yielded  any  information  that  one  had  not  already 
obtained,  and  its  use  was  abandoned  except  for  post-operative 
cases  where  the  patient  was  too  weak  to  stand  and  it  was 
necessary  to  determine  by  what  route  the  food  left  the 
stomach.  For  this  purpose  the  horizontal  position  sufficed, 
but  it  is  not  capable  of  yielding  reliable  data  as  to  the  stomach 
walls,  and  for  this  reason  I  think  it  futile  to  attempt  ordinary 
.r-ray  diagnosis  unless  the  patient  can  be  examined  in  the 
upright  position.     Another  point  that  determined  the  use  of 


8  Gastric  and  oesophageal  affections 

this  posture  was  the  fact  that  it  is  the  usual  position  during 
digestion,  and  it  is  while  this  process  is  going  on  that  the 
a'-ray  examination  is  made. 

The  best  view  of  the  stomach  is  obtained  with  the  abdomen 
against  the  screen,  but  in  certain  cases  it  was  found  that  the 
pyloric  portion  seemed  to  turn  somewhat  backwards  and  its 
shadow  was  thus  foreshortened,  but,  by  rotating  the  patient 
slightly,  this  portion  came  into  full  view.  The  pylorus  itself 
is  the  most  difficult  portion  to  see  clearly,  not  only  on 
account  of  the  small  quantity  of  food  that  it  usually  contains 
but  also  because  of  the  superimposed  shadow  of  the  vertebral 
column. 

(b)  In  oesophageal  cases.  The  upright  position  is  the  easiest 
and  most  useful  as  well  as  the  most  natural  for  oesophageal 
cases.  In  the  direct  antero-posterior  position  the  vertebral 
column  and  heart  form  a  very  heavy  shadow  through  which 
it  is  impossible  to  see  the  oesophagus  clearly,  but  if  the 
patient  is  slowly  rotated  so  that  the  front  of  the  right  shoulder 
is  against  the  screen,  a  certain  angle  is  found  at  which  these 
two  shadows  become  separate ;  a  comparatively  clear  space 
representing  the  posterior  mediastinum  is  opened  up,  and  it  is 
through  this  space  that  the  oesophagus  passes.  In  this 
position  the  whole  oesophagus  is  seen,  from  the  pharynx  to  the 
cardiac  orifice. 

6.  Preparation  of  the  Patient. 

Patients  should  be  prepared  for  all  abdominal  examinations 
as  if  for  an  anaesthetic  by  means  of  purgatives,  in  order  that 
the  stomach  may  be  empty  and  that  there  may  be  no1  shadows 
in  the  intestines  to  confuse  the  picture.  This  also  makes  the 
abdomen  much  more  translucent  to  the  rays,  consequently 
the  picture  of  the  stomach  full  of  bismuth  has  a  much  sharper 
outline  than  if  no  preparation  had  been  made.  These  patients 
are  frequently  taking  some  bismuth  mixture;  this  should  be 
discontinued  some  days  previously. 

No  special  preparation  is  of  course  necessary  for 
oesophageal  examination. 


Technique  9 

7.  Foods  Used. 

(a)  In  gastric  examinations.  The  essential  feature  of  the 
food  is  thai  ii  should  be  oi  sufficienl  difference  in  specifi< 
gravity  from  the  abdominal  contents  to  cast  .'1  definite  shado 
This  is  attained  by  embodying  in  ii  a  s.-ili  of  one  of  the  heavy 
metals.  Bismuth  subnitrate  was  used  in  the  early  cases,  as 
much  as  4  ozs.  being  taken  with  no  ill-effed  .  Reports  of 
cases  of  poisoning  wen-  published41  and  the  carbonate  of 
bismuth  was  subsequently  used,  the  proportion  being 
approximately  1  ounce  to  2  or  3  ounces  oi  the  excipient.  For 
stout  patients  the  quantity  was  increased  if  necessary  in  ordei 
to  get  a  denser  shadow.  The  oxychloride  of  bismuth  was 
tried,  but  I  could  find  no  difference  in  the  behaviour  of  the 
stomach,  although  this  salt  is  more  correct  theoretically  as  it 
is  not  acted  upon  by  hydrochloric  acid.  In  practice  I  have 
never  noted  the  evolution  of  C02  into  the  stomach  from  the 
use  of  the  carbonate,  and  1  find  that  patients  prefer  it  to  the 
oxychloride,  which  has  moreover  a  tendency  to  settle  out 
from  the  food,  making  the  detection  of  hypersecretion 
impossible. f  The  excipient  used  has  been  bread  and  milk, 
thoroughly  mashed  up,  or  porridge.  Other  excipients,  such 
as  mucilage  of  tragacanth,  pounded  biscuits,  cake,  bread  and 
butter,  mince  meat,  vegetables,  etc.,  have  been  tried  with 
more  or  less  success,  but  the  composition  of  the  food  seems 
to  be  of  no  practical  moment,  provided  it  does  not  nauseate  the 
patient.  The  addition  of  raspberry  syrup  has  been  of  some 
service  in  obviating  this  difficulty,  but  it  is  seldom  that 
patients  find  the  crude  mixture  too  distasteful. 

No  fixed  quantity  has  been  given,  but  sufficient  has  been 
used  in  each  case  to  dilate  the  potential  cavity  of  the  stomach 
to  such  an  extent  that  the  condition  of  the  walls  could  be 
deduced.     The  quantity,  therefore,  has  varied  from  2  ozs.  to 

*  At  least  two  cases  of  poisoning  occurred  in  America,  but  I  have  been 
unable  to  trace  the  references.  Bennecke  and  Hoffman  ("Munchener 
Medizinsche  Wochenschrift,"  1906.  No.  19)  recorded  a  fatal  case,  the  symptoms 
being  suggestive  of  nitrite  poisoning,  and  nitrites  were  found  both  in  the 
blood  and  pericardial  fluid.  Later  Bohmie  proved  that  the  administration  of 
bismuth  sub-nitrate  was  followed  by  the  appearance  of  nitrites  in  the  faeces 
and  urine,  but  not  in  the  blood. 

t  Specially  prepared  Barium  Sulphate  is  now  often  used  and  is  quite  satis- 
factory, except  that  it  appears  to  be  rather  stimulating  to  the  gastric  muscle 
and  makes  the  detection  of  the  duodenal  irritation  les-  certain. 


10  Gastric  and  oesophageal  affections 

|  pint — in  one  case  of  delusions  as  to  the  shape  of  the  stomach 
a  patient  took  4  pints  of  custard  mixed  with  bismuth  carbonate 
(8  ozs.)  with,  no  ill-effects. 

It  is  quite  unnecessary  to  give  purgatives  in  order  to  clear 
out  the  bismuth  after  the  examination.  In  large  doses  the 
salt  passes  through  unaltered  and  gives  rise  to  neither 
constipation  nor  diarrhoea. 

(b)  In  oesophageal  cases.  The  same  food  stuffs  have 
usually  been  employed  in  oesophageal  cases,  but  the  consist- 
ency has  been  varied  according  to  the  patient's  statement  as  to 
the  character  of  food  with  which  he  has  difficulty.  Cachets 
and  capsules  of  bismuth  have  been  discarded,  as  it  was  found 
that  they  gave  quite  unreliable  evidence;  in  a  healthy  subject 
a  gelatine  capsule  was  delayed  half  an  hour  at  the  cardiac 
orifice  in  spite  of  copious  draughts  of  water,  while  a  delay  of 
many  minutes  was  sometimes  seen  behind  the  aortic  arch. 
The  passage  of  a  solid  bougie  was  watched  in  one  case,  but 
its  use  appeared  to  be  so  dangerous  that  I  have  never  again 
employed  this  method. 

8.  Special  Methods. 

(a)  Physical  methods.  The  most  useful  special  method 
employed  is  the  application  of  abdominal  massage.  This 
practice,  which  I  introduced  about  three  years  ago,  has  been 
of  the  greatest  service,  since  by  its  use  it  is  almost  invariably 
possible  to  distinguish  between*  alterations  in  the  outline  of  the 
stomach  due  to  organic  lesions  and  those  due  to  spasm,  and 
where,  as  so  frequently  happens,  there  is  a  combination  of 
these  two  factors,  a  great  deal  of  information  may  usually  be 
obtained  as  to  the  respective  parts  played  by  each  in  deter- 
mining the  shape  of  the  resulting  shadow. 

Manipulation  either  by  hand  or  more  safely  with  a 
wooden  spoon  (as  suggested  by  Holzknecht)  during  the 
examination,  has  frequently  given  information  as  to  the  fixity 
or  otherwise  of  various  parts  of  the  stomach,  but  care  is  needed 
in  making  deductions  as  it  is  exceedingly  easy  to  mistake 
displacement  of  the  contents  for  displacement  of  the  stomach 
wall  itself. 


Technique  11 

Inflating  the  stomach  l>v  means  of  sodium  bicarbonate  and 
tartaric  acid  distends  the  fundus,  and  has  occasionally  yielded 
information  as  l<>  this  portion  oi  the  cavity,  but,  owing  to  tli«- 
impossibility  of  excluding  gastric  ulcer,  il   has  seldom  been 

used. 

In    the  early  cases,    when   good  definition    of   the  greater 

curvature  could  not  he  obtained,  I  found  that  injecting  air 
per  rectum  was  of  some  value,  and  in  a  few  cases  this  method 
showed  up  small  irregularities  that  would  otherwise  have 
escaped  notice. 

A  mixture  of  bismuth  and  lycopodium  has  been  tried  for 
more  clearly  demonstrating  the  level  of  fluids,  but  its  use  was 
unnecessary  and  it  has  been  abandoned. 

Capsules  made  of  gold-beater  skin  containing  bismuth 
have  been  given,  in  order  to  test  the  digestive  power  of  the 
gastric  juice  (suggested  by  Schwartz).  I  found  that  it  was 
not  possible  to  determine  at  what  time  the  capsules  ruptured 
and  also  that  very  frequently  they  were  broken  during  deglu- 
tition. As  no  other  bismuth  could  be  given  until  the 
observations  on  these  capsules  were  completed  their  use  has 
been  abandoned. 

(b)  Actions  of  drugs.  The  only  drugs  that  have  been 
examined  to  any  extent  have  been  sodium  bicarbonate,  bella- 
donna, valerian,  asafcetida,  and  alcohol. 

Valerian  and  asafcetida  have  been  found  to  diminish  tonic 
action  in  proportion  as  patients  found  them  distasteful. 
Those  who  disliked  the  smell  or  taste  most  showed  the 
greatest  loss  of  tone.  Alcohol,  on  the  other  hand,  tended  to  \, 
increase  tonic  action,  the  increase  being  more  or  less  propor- 
tionate to  the  patient's  appreciation  of  the  alcohol  (whisky) 
used  in  the  experiments. 

Belladonna  acted  in  an  uncertain  manner.  In  some  cases 
of  spasm  it  caused  complete  relaxation,  while  in  others  it  had 
little  or  no  effect.  In  one  or  two  cases  of  excessive  peristalsis 
this  symptom  was  checked  by  its  action.  No  cases  of  exces- 
sive secretion  have  been  tested  with  this  drug  as  yet. 

Sodium  bicarbonate  has  also  been  found  to  check  excessive 


12  Gastric  and  oesophageal  affections 

and  painful  peristalsis  in  a  wonderful  way  in  a  proportion  of 
cases,  while  in  others  it  has  produced  no  effect.  I  have  also 
lately  introduced  the  use  of  this  drug  for  testing,  in  a  very 
rough  but  handy  manner,  the  quantity  of  free  acid  in  the 
stomach.  In  healthy  subjects  there  is  well-marked  evolution 
of  carbon  dioxide,  but  in  every  case  of  marked  hypersecretion 
there  has  been  much  more  profuse  production  of  gas. 


13 


CHAPTER  III 

DIAGNOSIS  OF   AFFECTIONS  OF  THE 
(ESOPHAGUS. 

Possibly  none  of  the  many  striking  conditions  thai   are 

revealed  by  #-rays  is  so  dramalir.  as  the  demonstration  of 
oesophageal  obstruction.  A  dogmatic  positive  or  negative 
diagnosis  is  expected  and  is  freely  given  by  the  radiographer, 
and  it  is  usually  accepted  by  the  physician,  for  it  is  a  gener- 
ally accepted  axiom  thai  it  is  a  case  of  either  'guilty  '  or  '  not 
guilty,'  and  that  if  the  bismuth  food  passes  freely  down  the 
oesophagus  there  cannot  be  any  obstruction.  This  is  not 
the  case,  for  'obstruction'  is  a  relative  term  and  depends  on 
three  distinct  factors,  i.e.,  (i)  the  consistency  of  the  food  in 
relation  to  (2)  the  degree  of  obstruction  and  (3)  the  power  of 
the  oesophageal  peristalsis,  aided  by  the  action  of  gravity. 

The  oesophagus,  unlike  the  rest  of  the  alimentary  tract, 
has  approximately  only  one  function  namely  to  act  as  a  high- 
way from  the  mouth  to  the  stomach,  and  anything  that 
interferes  with  this  function  causes  the  symptom  of 
oesophageal  obstruction,  which  may  arise  from  a  variety  of 
causes.  It  is  frequently  the  first  and  only  sign  of  such  serious 
conditions  as  new  growths  and  aneurisms,  while  comparatively 
innocent  lesions  may  give  rise  to  precisely  the  same  trouble. 
I  am  convinced  that  in  some  of  these  latter,  the  patient's  life 
would  have  been  saved  bv  a  gastrostomy  if  the  operation  had 
not  been  put  off  too  long  on  the  supposition  that  it  was  due  to 
malignant  disease,  and  that  it  was  not  worth  operating  except 
to  avert  death  from  starvation. 

The  methods  of  investigation  available  and  their  limitations. 
Of  the  bougie  it  is  difficult  to  write  with  patience.  It  is  an 
act  of  crude  barbarity  to  pass  such  an  instrument  for  diagnostic 
purposes  into  a  tube  whose  walls  may  be  the  seat  of  simple  or 
malignant  ulceration  or  even  eroded  bv  an  aneurism,  if  other 


14  Gastric  and  oesophageal  affections 

less  dangerous  methods  are  available.  The  bougie  is  a  most 
useful  surgical  instrument,  and  in  a  large  proportion  of  eases 
it  is  the  right  instrument  to  employ  for  surgical  purposes,  but 
for  diagnosis  there  is  no  other  such  barbaric  relic  in  the  whole 
of  medicine  or  surgery.  Plummer's  method*  of  passing  a 
bougie,  threaded  on  a  swallowed  string,  seems  to  be  the  only 
safe  way  of  employing  this  instrument. 

The  cesophagoscope,  on  the  other  hand,  reveals  the  whole 
of  the  track  down  which  it  travels  but  that  is  all.  It  is  blind 
to  conditions  around  the  oesophagus  and  may  be  passed,  all 
unsuspectingly,  within  a  fraction  of  an  aneurism  or  growth  that 
by  its  pressure  is  causing  difficulty  in  swallowing. 

The  .r-ray  method  shows  the  shadow  of  the  food  in  the 
oesophagus.  It  does  not  show  the  oesophagus  itself,  but  it 
reveals  the  presence  of  aneurisms  and  large  new  growths, 
while  from  the  shape  and  behaviour  of  the  food  shadow  much 
may  be  learned  as  to  the  nature  of  the  lesion  that  gives  rise  to 
the  symptom.  Moreover,  it  has  two  very  great  advantages, 
it  is  entirely  free  from  danger  and  it  involves  no  distressing 
manipulative  procedure. 

The  Causes  of  (Esophageal  Obstruction. 

i  .  Those  due  to  pressure  from  without. 

2.  Those  due  to  changes  in  the  walls  themselves. 

3.  Foreign  bodies. 

4.  Reflex  causes. 

(1)  Due  to  external  pressure.     ((Esophageal  compression.) 
(a)  Aneurism. 
(6)  New  growth  in  the  neck,  mediastinum,  or  lungs. 

(c)  Enlarged  glands. 

(d)  Spinal    abscess    and    new   growths    arising    from    the 

vertebral  column. 

(e)  Bronchocele. 

The  diagnosis  of  these  conditions  does  not  fall  within  the 
scope  of  this  thesis  and  is  therefore  omitted. 

*H.  S.  Plummer,  -'Journal  of  American  Medical  Association, "  August,  1908, 
and  June,  1910  ;  J.  S.  Mayer,  ibid.,  October,  1910. 


c=*- 


Fiff.  2. 


v^~* 


ra 


Fig.  3. 


Fie,  \. 


Fig.  6. 


Fig.  1 .  Diagraraatic  representation  of  the  semi-lateral  view  of  the  posterior 
mediastinum  with  the  normal  course  of  the  oesophagus  indicated  by  the  dotted 
line.  (A.  Aorta.  H.  Heart.  JJ.  Diaphragm.  O.  Oesophagus.  V.  Vertebral 
column. 

Fig.  2.  Slight  dilatation  of  aortic  arch  with  delay  of  bismuth  above  it. 
No   real   obstruction. 

Fig.   3.    Large  aneurism  of  aortic  arch  with  oesophageal  obstruction. 

Fig.  4.  Growth  in  the  posterior  mediastinum  surrounding  and  obstructing 
the  oesophagus. 

Figs.  5  and  6  represent  obstruction  behind  the  aortic  arch  and  at  the  cardiac 
orifice  respectively. 


Causes  of  oesophageal  obstruction  15 

(2)  Due  to  causes  on  the  walls  themselves. 

(a)  New  growl  lis. 

(h)  Ulceration,   with  spasmodic  contraction, 

(c)  Cicatrization,  following   ulceration  from  caustics  and 
acids,  syphilis,  etc. 

It  is  seldom  that  these  cases  can  be  separated  from  one 
another.  The  growths  are  usually  too  small  to  cause  any 
distinct  shadow,  while  cicatrization,  ulceration,  and  spasmodic: 
contractions  give  exactly  similar  appearances.  Belladonna 
is  of  some  value  in  relaxing  the  spasmodic  element  in  these 
cases  I  find,  but  it  is  not  sufficiently  reliable  in  causing  relaxa- 
tion of  spasm  to  be  of  much  value  in  diagnosis. 

In  this  group  of  causes  there  are  nearly  always  two 
factors  to  consider,  i.e.,  the  organic  and  the  spasmodic,  and 
I  cannot  too  strongly  insist  on  the  importance  of  this  latter 
element  which  is  often  responsible  for  almost  the  whole  of 
the  symptomatic  disturbance. 

The  oesophagus,  like  the  rest  of  the  alimentary  tract,  is 
highly  sensitive,  and  a  small  abrasion  or  ulceration  may  set 
up  a  spasm  of  such  severity  and  persistence  that  complete 
obstruction  may  result.  The  severity  of  the  spasm  appears 
to  depend,  not  on  the  size  of  the  ulcer,  but  upon  its  irritability, 
for  I  examined  a  case  on  the  dav  following  operation  for 
removal  of  an  eroded  penny  that  had  been  lodged  in  the 
oesophagus  for  four  months,  and  found  only  the  slightest 
delay  with  quite  thick  food,  whereas  in  another  case,  which 
was  examined  by  the  cesophagoscope,  I  found  complete 
obstruction  with  dilatation  although  onlv  a  very  small  ulcer 
was  seen.  I  believe  that  simple,  or  peptic  ulceration  of  the 
oesophagus  is  of  far  more  frequent  occurrence  than  is 
commonly  taught. 

It  is  in  this  type  of  case  that  the  stage  of  dilatation  with 
leakage  or  temporary  recovery  is  sometimes  seen,  and  a 
certain  number  of  cases  of  simple  ulceration  are  met  with  in 
which  the  passing  of  a  bougie  may  so  stretch  the  base  of  the 
ulcer  that  healing  and  complete  relief  of  all  symptoms  may 
follow,  as  I  have  seen  on  two  occasions,  one  of  the  patients 
being  a  man  of  over  seventy. 


16  Gastric  and  oesophageal  affections 

The  use  of  the  bougie  should  never  be  attempted  unless 
the  bismuth  shadow  shows  a  definite  funnel-shape  at  its  lower 
end;  a  bougie  may  wander  in  an  amazing  fashion  far  away 
from  the  opening  into  the  passage.  Force  must  never  be 
used,  and  even  with  the  gentlest  manipulation  a  round-nosed 
bougie  may  pass  into  an  ulcer  and  down  between  the  mucous 
and  muscular  coats,  giving  a  sense  of  absence  of  obstruction 
that,  in  one  of  the  cases  I  examined,  led  to  the  death  of  the 
patient  from  direct  septic  extension  to  the  lungs. 

(3)  Foreign  bodies  in  the  oesophagus. 

Most  foreign  bodies  that  are  found  in  the  oesophagus  are 
opaque  to  the  .r-rays  and  the  bismuth  method  of  examination 
is  unnecessary  for  their  detection.  Plum-stones,  fish-bones, 
and  certain  kinds  of  tooth-plates  however,  throw  no  shadow 
that  can  be  distinguished,  and  in  a  few  of  these  cases  I  have 
been  able  to  demonstrate  their  presence  by  observing  the 
behaviour  of  the  bismuth  food  as  it  found  its  way  past  them. 
In  some  cases  the  stream  was  divided,  in  others  portions  of 
bismuth  were  left  adherent  to,  or  in  pockets  about,  the  foreign 
body.  On  the  whole,  however,  the  detection  of  these  trans- 
lucent bodies  has  not  been  satisfactory. 

(4)  Reflex  causes. 

(a)  New  growths  and  inflammatory  lesions  of  the  larynx 

and  in  the  neck. 

(b)  Ulceration  and  new  growths  of  the  cardiac  end  of  the 

stomach. 

(c)  Neurotic  and  hysterical. 

(a)  New  growths  and  inflammatory  lesions  of  the  larynx 
and  in  the  neck  are  readily  diagnosed  by  other  methods,  and 
it  is  very  exceptional  that  the  #-ray  examination  is  of  any 
value  except  in  demonstrating  that,  although  the  food  enters 
the  pharynx,  it  does  not  get  into  the  oesophagus. 

(b)  Ulceration  and  new  growths  of  the  cardiac  end  of  the 
stomach,  when  situated  close  to  the  cardiac  orifice  may  give 
rise  to  very  marked  obstruction,  (figs.  6  and  8.)  In  one  case  a 
healed  ulcer,  two  inches  from  the  orifice,  was  the  only  patho- 
logical   condition    noted    post-mortem    in    a    case    where    the 


Stages  of  oesophageal  obstruction  17 

patient  showed  all  the  signs  of  extreme  dilatation  of  the 
oesophagus.  This  had  led  to  surii  weakness  thai  the  patient 
died  from  the  shock  of  the  operation  of  gastrostomy.      In 

another  case,  where  marked  dilatation  had  taken  place  and  no 

food  appeared  to  enter  the  stomach,  advanced  can  [noma  was 
found,  but  it  did  not  involve  the  orifice  which  appeared  to  be 
quite  patent  and  normal  in  all  respects.  In  both  these  cases, 
although  dilatation  of  the  oesophagus  had  occurred,  the  post- 
mortem reports  state  that  the  oesophagus  was  not   dilated. 

*(c)  Neurotic  and  hysterical.  I  have  seen  no  cases  in  which 
this  diagnosis  was  confirmed,  but  neurotic  patients  frequently 
gave  trouble  by  stating  that  they  could  not  swallow. 
Persuasion  and  distraction  of  the  attention,  however,  usually 
overcame  this  difficulty  and  demonstrated  the  nature  of  the 
case. 

The  Stages  of  (Esophageal  Obstruction*. 

Whatever  the  cause  the  result  is  the  same  and  there  are 
three  definite  stages,  not  only  in  the  «-ray  appearances,  but 
also  in  the  clinical  history  of  the  cases. 

Stage  1.  Difficulty  in  swallowing.  (Most  marked  in  upper 
part  of  the  oesophagus.) 

This  is  the  stage  of  difficulty  in  swallowing.  The  patient 
has  not  lost  weight  but  gives  a  history  of  some  difficulty  in 
swallowing,  especially  when  he  tries  to  eat  his  food  fast  and 
without  mastication.  Usually  there  is  little  or  no  pain, 
provided  he  masticates  carefully  and  eats  slowly,  but  he  often 
states  that  he  has  to  force  each  mouthful  down  separately. 

On  examination  with  the  ordinary  type  of  bismuth 
porridge  it  is  probable  that,  at  the  most,  a  little  delay  is  noted 
at  one  particular  part.      If,  on  the  other  hand,  we  make  up 

•Recently  I  saw  a  case  in  which  it  was  evident  that  the  patient  had  to  push 
each  mouthful  down  the  oesophagus  by  sheer  forceful  deglutition  as  far  as  the 
level  of  the  clavicle.  There  was  evidently  no  obstruction  beyond  this  point, 
the  food  passed  down  quite  freely  and  easily  and  not  a  trace  was  left  adhering 
to  the  walls,  while  in  the  upper  third  traces  of  the  food  remained  for  a  long 
time.  It  was  quite  clear  there  was  paralysis  in  the  upper  third,  while  the 
lower  two-thirds  were  quite  normal.  On  making  enquiry  from  Professor  Elliott 
Smith,  I  found  that  he  had  just  traced  out  a  dual  nerve  supply  arising  from  two 
separate  nuclei  in  the  medulla,  while  the  same  observation  had  been  made  by 
Van  Gehuchten  and  Molhant  6  months  previously  ("  Le  Xevraxe."  June.  15. 
1912,  p.  55). 


18  Gastric  and  oesophageal  affections 

our  bread  and  milk  with  lumps  in  it  and  make  the  patient  eat 
it  quickly,  we  may  find  that  there  is  definite  delay  at  this  same 
point,  and  occasionally  one  sees  a  violent  peristaltic  wave 
squeeze  the  food  almost  into  a  ball  and  force  it  through  the 
obstruction. 

The  oesophagus  is  called  upon  to  do  an  excessive  amount 
of  work,  consequently  hypertrophy  occurs — it  is  the  stage  of 
compensatory  hypertrophy,  and  for  the  time  being  compen- 
sation is  established. 


Stage  2.      Pain  after  swallowing.      (Not  so  well-marked  in 
the  lower  as  in  the  upper  parts  of  the  oesophagus.) 

This  is  the  stage  of  painful  deglutition  and  the  patient  has 
begun  to  lose  flesh.  He  states  that  he  cannot  swallow  solids 
at  all  and  that  even  gruel  sometimes  regurgitates  into  his 
mouth  but  he  never  actually  vomits.  Trie  pain  after  swallow- 
ing of  food  is  the  main  feature,  and  it  is  his  dread  of  eating, 
far  more  than  the  actual  obstruction,  that  leads  to  the  wasting, 
for  although  the  food  he  eats  is  eventually  forced  through, 
yet  the  pain  is  such  that  he  prefers  starvation. 

On  examination  there  is  definite  delay  at  the  point  of 
obstruction ;  there  is  seldom  any  mistake  in  the  diagnosis 
unless  some  such  thin  mixture  as  milk  and  bismuth  is  used, 
which  may  pass  through  unobstructed.  The  food  is  held  up, 
it  cannot  pass  on,  and  the  oesophageal  walls  bring  all  their 
peristaltic  power  to  bear  on  the  obstruction,  and  as  the  power- 
ful waves  move  downwards,  the  food  being  unable  to  pass 
through  the  obstruction  escapes  upwards  in  a  narrow  stream 
through  the  descending  contraction.  When  one  sees  the 
picture  one  is  not  surprised  that  it  is  the  stage  in  which  pain  is 
the  marked  feature — it  is  sometmes  so  marked  that  it  suggests 
a  life  and  death  struggle.  The  waves  are  not  a  continuous 
succession  of  contractions ;  it  is  a  case  of  one  great  effort 
followed  by  a  period  of  comparative  rest  while  the  muscle 
braces  itself  up  for  another  powerful  contraction.  This 
curious  intermittent  feature  of  the  contractions  is,  I  believe, 
characteristic    of    failing    compensation,     not    only     in    the 


Fig.  7.  Radiogram  of  oesophageal  obstruction  at  the  level  of  the 
6th  dorsal  vertebra.  The  cause  in  this  case  was  a  small  peptic  ulcer. 
The  spasm  that  caused  the  obstruction  was  only  brought  on  by  giving 
dry  bread.  It  was  after  this  procedure  that  the  bismuth  food  was 
given,  and  the  radiogram  indicates  the  complete  obstruction  that  has 
resulted. 


Fig.  S.  Spasmodic  oesophageal  obstruction '(cardiospasm),  (a)  The 
dilated  oesophagus,  (b)  Bismuth  food  that  entered  the  stomach  more  or 
Less  in  a  rush,  indicating  the  spasmodic  nature  of  the  lesion  very  clearly 
in  this  case. 


Stages  of  oesophageal  obstruction  19 

oesophagus  but  also   in  the  stomach,   in  certain   stages  of 

pyloric  obstruction. 

In  this  stage  the  compensation  is  failing  and  hypertrophy 
is  about  to  give  place  to  dilatation. 

Stage  3.     Dilatation. 

(Naturally,  in  cases  where  the  obstruction  is  high  up  and 
the  oesophagus  has  no  room  to  dilate,  this  stage  is  not  so 
well  marked  as  in  the  lower  two-thirds  of  its  course.) 

Clinically,  it  is  the  stage  of  starvation  and  the  patient  is 
rapidly  losing  flesh,  but  the  pain  and  difficulty  in  and  after 
swallowing  are  comparatively  slight,  so  that  the  patient  feels 
and  often  becomes  better  for  a  time.  There  is  no  longer  any 
actual  difficulty  in  making  the  food  pass  down,  but  sooner  or 
later  it  is  brought  up  again — the  lower  down  the  obstruction 
and  the  greater  the  degree  of  dilatation  the  longer  will  the 
food  be  retained,  so  much  so  that  in  marked  cases  a  diagnosis 
of  pyloric  obstruction  is  not  at  all  infrequently  made.  In  one 
of  these  cases  quite  considerable  quantities  of  bismuth  were 
found  in  the  dilated  pouch  that  extended  above  the  diaphragm 
two  days  after  it  had  been  given,  and  the  patient  gave  a 
history  of  having  recognised  in  his  vomitus,  food  that  he  had 
taken  some  days  previously.  Indeed,  in  a  few  cases,  it  is 
absolutely  impossible  to  recognise  whether  the  trouble  is 
oesophageal  or  gastric,  for  the  food  returned  from  such  a 
pouch  has  the  same  acid  smell  as  gastric  vomit,  and  fermenta- 
tion takes  place  just  as  readily  in  a  dilated  oesophagus  as  it 
does  in  the  stomach  in  pyloric  obstruction.  Moreover,  the 
stomach  tube  may  give  most  misleading  information,  for 
instead  of  stopping  at  the  obstruction  it  may  just  as  readily 
pass  into  the  pouch,  whose  thin  walls  give  little  sense  of  resist- 
ance. I  have  seen  a  tongue,  i\  inches  long,  pushed  out  from 
a  sac  over  the  dome  of  the  diaphragm  by  the  sheer  weight  of 
the  tube  in  a  fraction  of  a  second,  in  a  case  where  an  entry  in 
the  notes  stated  that  bougies  had  been  passed  into  the 
stomach.  On  more  than  one  occasion  I  have  found  complete 
obstruction  in  cases  diagnosed  as  carcinoma  of  the  stomach, 


20  Gastric  and  oesophageal  affections 

on  the  evidence  of  the  chemical  examination  of  a  test  meal 
that  could  not  possibly  have  been  in  the  stomach. 

It  would  be  expected  that  this  state  of  affairs  could  not 
last  long,  but  when  the  cause  is  in  part  spasmodic,  the  com- 
plete relaxation  of  the  tone  that  allows  the  dilatation  also 
relaxes  the  spasm,  and  this  is  often  the  most  important 
element  in  the  obstruction.  When  the  cause  is  not  rapidly 
progressive,  a  cycle  may  be  established  reverting  between  the 
second  and  third  stages.  Such  cases  are  sometimes  due  to 
simple  or  peptic  ulceration,  which  I  believe  to  be  of  more 
frequent  occurrence  than  is  commonly  supposed.  The  ulcer 
causes  a  spasmodic  obstruction  that  follows  through  the  usual 
three  stages  till  dilatation  is  established.  After  a  time  the 
oesophagus  is  too  worn  out  to  keep  up  its  spasmodic  contrac- 
tion in  spite  of  the  source  of  irritation,  and  relaxation  takes 
place  so  that  food  passes  through.  Soon  the  muscle  recovers 
its  power  and  contracts  on  the  ulcerated  surface  and  again  the 
spasm  is  produced.  In  the  larger  number  of  cases  however, 
a  compromise  is  effected  and  there  is  no  definite  cycle,  a  more 
or  less  permanent  condition  of  dilatation  with  leakage  being 
the  result,  so  that  the  patient  lives  in  comparative  comfort  but 
in  a  state  of  semi-starvation. 

On  examination,  no  matter  what  the  consistency  of  the 
food,  it  simply  flows  into  the  oesophagus  and  lies  in  the 
dilated  sac,  for  there  are  no  peristaltic  waves  of  sufficient  force 
to  disturb  it.  If  the  sac  is  called  upon  to  hold  more  than  a 
certain  quantity,  either  the  patient  must  vomit  or  the  sac  must 
dilate  still  further.  Sometimes  dilatation  is  carried  to  an 
extreme,  especially  in  the  lower  part  of  the  oesophagus.  The 
pouch  distends  along  the  line  of  least  resistance  which  is  by 
displacement  of  the  lung  and  burrows  forward  over  the 
dome  of  the  diaphragm,  occasionally  even  displacing  the 
heart  to  some  extent. 

Pathologically,  it  is  the  stage  where  compensation  has 
failed.  The  fight  in  which  the  musculature  has  called  up  all 
its  reserves  has  ended  in  defeat.  The  hypertrophied  wall  is 
dilated,  thinned  out,  and  incapable  of  effective  contraction. 
One  would  expect  that  at  the  post-mortem  we  should  find  this 


Stages  of  oesophageal  obstruction  21 

state  of  affairs  as  in  life,  bul  it  is  very  seldom  that  it  is  recorded 
in  the  post-mortem  notes.  The  only  explanation  I  ran 
suggesl  is,  thai  although  the  oesophagus  has  been  so  distorted 
during  life,  in  death  the  same  conditions  do  not  exist. 
Probably  rigor  mortis  and  the  contraction  of  the  elastic 
elements  of  the  muscle  restore  the  oesophagus  to  a  semblance 
of  the  normal. 

Like  all  involuntary  muscles  the  oesophagus  has  a  wonder- 
ful power  of  recovery,  and  even  a  grossly  dilated  oesophagus 
may  completely  recover  its  activity  and  tone  in  a  very  short 
time  if  rest  can  be  secured,  i.e.,  if  the  obstruction  can  be 
reduced  or  feeding  carried  on  by  some  other  method.  In  one 
patient,  a  woman,  in  whom  the  oesophageal  shadow  was  noted 
as  two  inches  in  diameter,  the  obstruction  yielded  of  its  own 
accord,  and  when  I  saw  her  a  week  later  it  was  impossible, 
even  with  solid  food,  to  note  any  abnormality. 


22 


CHAPTER  IV. 
THE  NORMAL  STOMACH. 

The  anatomy  of  the  soft  parts,  as  seen  in  the  dissecting 
room,  is  not  necessarily  a  true  index  to  the  condition  found 
in  life,  and  although  the  stomach  is  retort-shaped  after  death 
or  on  the  operating  table,  it  is  a  very  different  organ  as  it 
fulfils  its  functions  in  life  and  with  the  patient  in  the  upright 
position.  Like  the  rest  of  the  alimentary  canal  it  is  tubular, 
more  or  less  J  shaped,  and  almost  entirely  to  the  left  of  the 
middle  line.  The  lowest  part  reaches  to  about  the  level  of 
the  umbilicus*  and  the  pylorus  is  perhaps  an  inch  higher  and 
slightly  to  the  right  of  the  middle  line,  but  these  data  are 
approximate  only,  as  in  practice  it  is  found  that  even  in 
patients  who  do  not  know  what  indigestion  is,  the  shape  of 
the  shadow  differs  widely.  Generally  speaking,  this  is  due  to 
defective  tonic  action,  and  therefore  it  is  essental  that  this 
property  of  the  gastric  muscle  should  be  grasped  before  any 
attempt  is  made  to  detect  pathological  changes. 

The  increased  capacity  for  food  is  obtained  by  lateral 
expansion  of  the  tube,  which  should  hold  its  contents  up 
against  the  action  of  gravity  at  a  fixed  level,  and  it  is  the  tonic 
action  (see  page  24)  of  the  gastric  muscle  that  is  responsible 
for  this  maintenance  of  the  fluid  level  in  the  upright  position. 

The  lowest  border  should  not  move  wth  respiration,  and 
compensation  for  diaphragmatic  movement  is  automatically 
taken  up  by  the  stomach  walls. 

In  a  paper  t  before  the  Electro-therapeutic  section  of  the 
Royal  Society  of  Medicine,  I  showed  that  the  contents  are  not 
churned  up  but  take  up  their  positions  according  to  their 
specific  gravities,  except  in  the  pars  pylorica  when  the  peris- 
talsis is  active ;  consequently  air  always  occupies  the  fundus, 

*  The  level  of  the  umbilicus  is  practically  the  same  as  that  of  the  iliac  crests, 
so  that  there  is  no  need  to  place  a  coin  or  other  mark  on  this  point  to  show  its 
position. 

t  "Proc.  Roy.  Soc.  Med.,"  Feb.,  1909. 


Fig.   11. 


Fig.  12. 


Fig.  13. 


Fig.  14. 


Fig.  9.     Air  in   fundus  of  the  empty   stomach    (A.S.).     H.  :    Heart.     D.  : 
Diaphragm.     0.  :    Umbilicus.     I.C.  :   Iliac   crest.     S.P.  :    Symphysis  pubis. 
Fig.  10.    Air  in  the  fundus  (A.S.)  of  a  stomach  that  already  contains  fluid. 

Figs.  11,  12,   13,  14. 
Diagrams  illustrate  the  filling  of  a  normal  stomach     B.  :   Bismuth 
food.     CO.  :  Cardiac  orifice.     A.  and  B.  in  Fig.  12  indicate  peristaltic  waves. 


The  normal  stomach  23 

and  the  heavier  food  gravitates  to  the  lowesl  part.  Hence 
the  bismuth  food  outlines  the  lowest  border  in  all  cases. 

The  fundus  occupies  the  left  cupola  of  the  diaphragm  and 

usually  contains  air  which  shows  as  a  light  area  below  the 
shadow  of  the  heart. 

If  the  stomach  is  empty,  the  air  appears  as  an  oval  shadow, 
while  if  there  is  a  quantity  of  food  in  the  stomach,  the  shadow 
represents  the  arc  of  a  circle,  its  lower  border  being  a  straight 
line  which  can  be  demonstrated  as  fluid  by  watching  the 
ripples  on  its  surface  on  shaking  the  patient. 

The  empty  stomach  is  a  potential  space,  and  into  it  the 
bismuth  food  passes.  The  weight  of  a  single  mouthful  may 
not  be  sufficient  to  canalize  the  potential  cavity  for  a  little 
time  and  hence  the  food  stays  in  the  upper  part  just  below 
the  air,  but  as  more  is  given  the  shadow  is  seen  passing 
downwards  to  the  lowest  point,  and  after  a  short  time  the 
pyloric  antrum  is  filled.  After  two  or  three  mouthfuls  have 
been  swallowed  the  shape  of  the  shadow  should  be  like  the 
letter  'J,'  and  as  more  food  is  given  the  increased  capacity  is 
obtained  by  the  lateral  expansion  of  the  shadow,  and  not  by 
any  appreciable  drop  in  the  position  of  the  lowest  border,  or 
raising  of  the  upper  level  of  the  shadow.* 

It  has  been  stated  that  the  shadow  of  the  bismuth  filled 
stomach  does  not  represent  the  normal  shape ;  that  the  actual 
weight  of  the  food  causes  a  distorted  appearance.  This, 
however,  can  be  easily  disproved  by  giving  an  ordinary  meal 
and  then  watching  a  thin  watery  suspension  of  bismuth 
permeate  the  ordinary  food.  The  shape  of  the  organ  obtained 
in  this  way  differs  in  no  detail  from  that  obtained  with  the 
usual  bismuth  method. 

I  have  found  that  in  infants  the  shape  of  the  organ  is 
much  more  globular  and  during  the  first  year  of  life  is  com- 
paratively  spherical,    but  as   the  child   assumes   the    upright 

*  The  description  of  the  normal  stomach  is  purposely  vague — it  is  as 
fruitless  to  apply  the  precision  of  descriptive  anatomy  to  such  an  organ  as  it 
would  be  to  give  exact  figures  and  shapes  for  an  indiarubber  balloon.  Its 
capacity  varies  from  zero  to  many  pints,  while  its  shape  is  determined  not 
only  by  its  tonic  action  and  the  quantity  of  food  it  contains  but  also  by  the 
pressure  of  the  other  intra-abdominal  organs,  particularly  by  the  presence  or 
absence  of  gas  in  the  splenic  flexure. 


j 

N 


24  Gastric  and  oesophageal  affections 

position  the  stomach  elongates.  It  is  not,  however,  till  near 
the  age  of  puberty  that  the  lower  border  descends  to  the 
umbilicus. 

The  stomach  is  not  a  fixed  organ  and  it  is  easily  displaced 
by  even  slight  forces.  For  instance  if  the  splenic  flexure  is 
distended  with  gas  the  stomach  may  be  displaced  to  the  right, 
or  if  the  patient's  abdomen  is  pressed  upon,  the  lowest  border 
may  be  moved  upwards  by  two  inches  or  more. 

This  is  the  description  of  the  normal  stomach,  but,  as  I 
have  already  said,  it  is  by  no  means  always  found  in  persons 
who  have  never  suffered  from  any  gastric  trouble.  It  is  a  fact 
that  the  stomach  may  present  an  appearance  that  is  far  from 
normal  and  yet  fulfil  its  functions  perfectly.  The  part  played 
by  tonic  action  or  defective  tonic  action  in  the  appearances 
seen  is  the  key  note  to  correct  interpretation  in  these  cases, 
and  will  therefore  be  considered. 

Tonic  action. 

The  upper  border  of  the  contents  should  be  about  the 
cardiac  orifice,  and  the  increased  capacity  for  more  food 
should  be  obtained  by  a  widening  of  the  tube.  (See  figs,  n  to 
14.)  Tonic  action,  therefore,  may  be  defined  as  the  constant 
contraction  of  the  stomach  which  maintains  the  contents  in 
tubular  form,  i.e.,  it  is  an  automatic  contraction  that  counter- 
balances the  action  of  gravity  on  the  stomach  contents.  In 
the  recumbent  position  therefore,  the  tonic  action  is  not  called 
upon  to  anything  like  the  same  extent,  and  it  seems  reason- 
able to  suppose  that  the  benefit  received  by  patients  suffering 
from  atony  from  rest  in  bed  is  due,  in  part  at  least,  to  the 
relief  of  the  constant  strain  on  this  function. 

A  thorough  understanding  of  this  property  of  the  muscle 
is  invaluable  in  gastric  radioscopy.  Tone  is  a  property  of 
the  living  muscle,  and  is  therefore  not  seen  either  in  the  post- 
mortem room  or  as  a  rule  on  the  operating  table.  It  is  under 
the  control  of  the  central  nervous  system,  and  may  alter  very 
rapidly.  For  instance,  everyone  knows  the  sinking  feeling 
that  accompanies  nausea,  sudden  fear,  and  disgusting  smells, 
and  in  these  conditions  I  have  invariably  found  that  this  sink- 
ing sensation  in  the  abdomen  is  accompanied  by  an  actual 


Peristalsis  25 

relaxation  of  the  (one,  and  consequently  by  a  drop  in  the 
level  of  the  lower  border  of  the  stomach,  while  an  increase  in 

the  tone  accompanies  tin-  actual  process  of  vomiting  and 
retching.     I  have  made  many  experiments  on  toni<    action 

with  various  drugs  such  as  valerian  and  asafcctida,  and  the  loss 
of  tone  seemed  to  be  in  direct  proportion  to  the  disgust  in 
almost  every  case. 

Loss  of  tone  is  often  associated  with  loss  of  appetite,  while 
appreciation  of  food  tends  not  only  to  stimulate  the  flow  of 
gastric  juice,  as  we  know,  but  also  to  increase  the  tone. 
Peristalsis. 

It  should  be  possible  to  make  out  the  peristaltic  move- 
ments in  all  except  very  stout  patients,  and  they  appear  to  be 
always  present  from  the  time  food  enters  the  stomach  till  it  is 
empty.  The  waves  start  opposite  the  cardiac  orifice  and 
sweep  along  the  greater  curvature,  gaining  in  force  as  they 
approach  the  pylorus. 

On  the  lesser  curvature  the  waves  are  not  seen  so  high 
up.  When  they  actually  segment  the  bismuth  shadow, 
some  distance  from  the  pylorus,  the  peristalsis  is  more 
powerful  than  normal,  but  peristalsis  is  so  variable  that 
no  conclusions  should  be  drawn  from  this  sign,  unless  the 
waves  are  persistently  noted  as  excessive  on  several  occasions. 

The  persistent  absence  of  peristalsis  in  a  stomach  otherwise 
normal  in  appearance  but  containing  retained  food,  is 
associated  with  extensive  ulceration — usually  malignant — 
involving  the  pyloric  region  and  giving  rise  to  obstruction. 

Naturally,  in  a  thinned  out  atonic  stomach,  the  peristalsis 
is  likely  to  be  much  less  powerful  than  in  a  normal  stomach, 
but  even  in  extreme  cases,  when  the  lowest  part  is  almost  in 
die  pelvis,  peristalsis  can  always  be  elicited  by  massage.  In 
these  cases  it  is  difficult  to  observe  the  movements,  the  shadow 
of  the  sacrum  and  ilium  obstruct  the  view,  and  unless  the 
£-ray  tube  is  working  well  it  may  be  impossible  to  make  certain 
of  this  point. 

Reverse  peristalsis  is  very  seldom  seen  in  this  country  and 
when  met  with  it  indicates  gross  pathological  changes,  usually 
at  the  pylorus,  but  I  have  only  seen  it  in  six  cases. 


26  Gastric  and  oesophageal  affections 

The  control  of  the  pylorus. 

By  means  of  giving  sodium  bicarbonate  and  observing  the 
evolution  of  carbon  dioxide,  the  acidity  of  the  gastric  contents 
can  be  roughly  estimated,  and  it  is  certainly  not  in  those  cases 
in  which  the  evolution  of  gas  is  greatest  that  the  pylorus  opens 
most  freely,  but  in  the  class  of  case  that  I  have  styled  '  duo- 
denal irritation  '  (p.  55).  In  this  type  of  case  the  food  is  seen 
passing  out  almost  at  once  into  the  duodenum  and  continuing 
to  pass  on  until  the  stomach  is  empty;  one  does  not  see  any 
hypersecretion  and  the  evolution  of  gas  is  not  more  than  in 
healthy  people.  It  looks  therefore  as  if  the  degree  of  acidity 
of  the  gastric  contents  is  not  the    determining  factor. 

Such  evidence  as  I  have  seems  to  prove  that  fatty 
foods  tend  to  remain  longer  in  the  stomach  than  the  carbo- 
hydrate and  proteid  meals  usually  employed,  but  I  have  not 
noted  any  difference  in  this  respect  between  the  porridge  and 
bread  and  milk  bismuth  meals. 

The  rapid  emptying  in  the  duodenal  cases  is  most  striking. 
Not  only  does  the  food  go  through  more  rapidly  but  also  the 
pyloric  relaxation  seems  to  be  much  more  complete  than  in 
the  healthy  subject,  with  the  result  that  quite  large  quantities 
pass  through  at  a  time  and  are  easily  seen  on  the  fluorescent 
screen,  in  contrast  with  the  finer  division  and  thin  stream  in 
which  the  food  leaves  the  stomach  in  perfectly  healthy 
subjects,  which  can  only  be  detected  on  the  fluorescent  screen 
under  the  most  favourable  conditions.  In  a  certain  number 
of  these  I  have  also  noted  that  the  pylorus  did  not  open  at 
once  and  no  food  was  seen  passing  through  for  perhaps  ten 
minutes,  but  when  once  shadows  were  seen  in  the  duodenum, 
the  stomach  began  to  empty  rapidly  as  if  the  mere 
presence  of  food  in  the  duodenum  brought  about  pyloric 
relaxation.  In  every  case  of  actual  ulceration  of  the 
duodenum  this  rapid  emptying  has  been  noted,  whether  the 
meal  was  made  up  of  bread  and  milk  or  of  porridge. 
Distending  the  duodenum  does  not  bring  about  closure  of 
the  pylorus,  rather  the  reverse,  so  far  as  I  can  tell  from  obser- 
vations on  a  limited  number  of  cases  in  which  this  portion  of 
the  intestine  has  been  overloaded   either  artificially  by  giving 


Control  of  peristalsis  and  tonic  action  27 

a  very  large  meal,  or  pathologically  by  reason  of  cicatrization. 

These  observations  suggest  very  strongly  thai  the  control 

of  the  pylorus  is  regulated  by  some  sensory  mechanism  in  the 

duodenum,  and  an  irritable  slate  of  this  part  of  the  gtlt, 
whether  intrinsic  or  reflex,  tends  to  abnormal  pyloric  relaxa- 
tion. In  two  cases  this  relaxation  was  so  marked  thai  I 
actually  pressed  a  large  quantity  of  food  through  the  sphincter 
by  manipulating  the  stomach  through  the  abdominal   wall. 

The  control  of  peristalsis  and  tonic  action. 

As  I  have  pointed  out,*  1  believe  that  tonic  action  and 
peristalsis  are  entirely  separate  and  independent  muscular 
functions.  The  evidence  on  which  this  opinion  is  based  is 
that  even  in  the  cases  where  atony  was  most  marked,  peris- 
talsis was  quite  well  seen,  while  in  a  limited  number  of 
instances  (type  2  of  chronic  pyloric  obstruction)-^-  an  exactly 
opposite  state  of  affairs  was  found,  i.e.,  perfect  tonic  action 
with  complete  and  persistent  absence  of  peristalsis. 

That  both  of  these  functions  are  influenced  by  the  central 
nervous  system  has  been  demonstrated  in  a  variety  of  ways. 
For  instance,  tonic  action  and  even  spasmodic  contractions 
have  been  relaxed  when  patients  have  been  frightened.  When 
patients  have  become  faint  I  have  nearly  always  had  warning 
by  seeing  a  sudden  relaxation  of  tonic  action — an  observation 
that  has  sometimes  saved  the  patient  from  a  nasty  fall.  If 
there  are  a  number  of  observers  present  the  patient  tends  to 
become  nervous,  and  often  I  have  failed  to  demonstrate  exces- 
sive peristalsis  and  hypertonic  conditions  that  were  invariably 
present  when  I  carried  out  the  observations  by  myself.  The 
influence  of  nauseating  smells  in  causing  relaxation  of  tone 
has  already  been  referred  to. 

*  Proc.  Roy.   Soc.  Med.,  Electro-Therapeutic  Section,  Feb.,   1909,  p.  9. 
t  In  advanced  cases  of  pyloric  obstruction  two  definite  and  widely  differing 
types  are  met  with  and  will  be  discussed  in  detail  later  (p.  33) : — 

Type  1.  Is  far  the  most  common.  The  stomach  is  extremely  atonic  and 
sags  down  into  the  pelvis.  Peristalsis  may  be  quite  active  and  yet  the  food 
may  be  retained  for  days. 

Type  2.  Is  rare.  The  stomach  is  normal  in  shape,  but  distended  with 
retained  food,  and  the  bismuth  is  seen  in  the  stomach  for  24  hours  or 
longer.  Frequently  in  these  cases  no  peristalsis  is  seen  and  no  movement  can 
be  evoked  by  massage. 


«J 


28  Gastric  and  oesophageal  affections 

In  the  earlv  stages  of  pyloric  obstruction,  as  we  should 
expect,  peristalsis  is  more  marked  than  in  health,  but  the 
phenomenon  of  very  active  peristalsis  and  hypertony,  in 
association  with  an  abnormally  patent  pylorus  in  cases  of 
duodenal  ulcer  and  duodenal  irritation,  suggest,  that  these 
functions  of  the  musculature  are  also  influenced  by  some 
reflex  connection  with  the  duodenum. 

In  the  cases  referred  to  as  type  2,  of  chronic  pyloric 
obstruction,  we  have  complete  absence  of  peristalsis.  Neither 
massage  nor  electrical  stimulation  seem  to  be  of  any  avail  in 
eliciting  contractions.  In  these  cases  also  an  almost 
hypertonic  condition  persists  and  is  quite  uninfluenced  by 
attempting  to  induce  nausea.  It  is  most  striking  that  it  is 
only  in  this  class  of  case  that  neither  of  these  functions  can 
be  influenced  by  any  means  I  have  tried,  and  the  inference  is 
that  the  nerve  supply  which  regulates  them  is  cut  off.  The 
actual  pathological  lesion  found  has  always  been  of  an  exten- 
sive nature  involving  the  lesser  curvature  in  the  pyloric 
region,  and  presumably  this  is  where  the  nerve  supply  passes 
into  the  stomach  from  the  duodenum,  either  directly  or 
through  sympathetic  ganglia.  The  injury  to  these  nerves 
produces  a  complete  absence  of  peristalsis  while  tonic  action 
is  very  pronounced,  a  condition  that  is  in  marked  contrast  to 
the  usual  atonic  condition  found  in  type  1  of  chronic  pyloric 
obstruction.  It  looks,  therefore,  as  if  tonic  action  is 
an  intrinsic  muscular  endowment,  or  that  there  are  centres 
controlling  this  function  in  the  stomach  wall  itself  or  connect- 
ing with  the  vagus  and  acting  in  a  similar  manner  to  the 
centres  in  the  lumbar  enlargement  for  the  regulation  of 
micturition.  In  the  vast  majority  of  chronic  pyloric  obstruc- 
tion cases,  I  have  found  that  peristalsis  is  present  and  that  the 
stomach  is  atonic.  In  some  of  these  the  pathological  condi- 
tions were  precisely  similar  to  those  found  in  the  rarer  type  of 
case.  If  therefore  my  deductions  are  correct,  it  seems 
probable  that  the  production  of  one  or  other  type  depends  on 
whether  or  not  these  communicating  nerve  fibres  are  inter- 
fered with  by  the  progress  of  the  disease. 


Notes  on  cases  29 

Notes  on  Cases  in  which  the  Operation  revealed  a 

Normal  STOMACH.    (Cases  on  p.  y<jj. 

In  the  cases  filed  under  this  head  are  included  only  those 
in  which  no  abnormality  involving  the  stomach  was  found  at 
the  operation,  witli  the  exception  of  the  duodenal  cases,  and 
those  in  which  the  #- ray  picture  of  'duodenal  irritation'  was 
present,  which  have  been  tabulated  under  ,-i  separate  heading. 

For  a  description  of  the  normal  stomach,  see  p.   22. 

In  many  apparently  normal  stomachs  a  certain  degree  of 
spasmodic  contraction  of  the  middle  of  the  body  was  noted, 
but  in  most  of  them  the  application  of  massage  to  the  abdomen 
relaxed  the  spasm  at  once,  while  in  a  small  number,  notably 
Nos.  369  and  398,  the  contraction  was  thought  to  be  organic 
in  origin  as  it  could  not  be  relaxed  by  massage  or  the  adminis- 
tration of  belladonna.  In  case  398  this  spasm  persisted,  and 
was  so  definite  that  at  my  instance  the  surgeon  again  explored 
and  found  nothing  whatever  to  account  for  it;  while  in  case 
369  the  simple  manipulation  of  the  stomach  at  the  operation 
was  sufficient  to  effect  a  perfect  cure,  and  re-examination  after 
the  laparotomy  showed  no  trace  of  the  contraction  previously 
noted. 

Displacement  of  the  lower  part  of  the  stomach  is  often 
met  with.  The  most  common  cause  is  distention  of  the  colon 
with  air  or  fasces,  and  the  examination  24  hours  later  will 
nearly  always  make  this  point  quite  clear.  Adhesions  and 
new  growths  are  also  factors  in  displacements,  and  the  detec- 
tion of  these  conditions  depends,  as  a  rule,  on  manipulation 
of  the  organ,  preferably  when  the  colon  is  also  filled  with 
bismuth.  Under  this  heading  are  tabulated  only  those  cases 
in  which  the  stomach  itself  was  not  involved  by  the  lesion. 

Case  296  is  curious,  in  that  several  observers  detected  a 
definite  abdominal  tumour  near  the  pylorus.  Radiographic- 
ally  I  found  no  evidence  of  any  abnormality,  and  no  tumour 
could  be  found  at  the  operation. 

Slight  or  even  marked  atony  was  noted  fairly  frequently 
but  was  regarded  rather  as  deficient  physiological  contraction 
than  as  a  pathological  condition. 


30 


CHAPTER  V. 

THE    PATHOLOGICAL    STOMACH. 
ATONY* 

Atony,  the  failure  of  the  muscle  to  maintain  the  tubular 
form  against  the  action  of  gravity,  is  a  complication  of  many 
pathological  conditions  of  the  stomach,  and  the  part  played 
by  atony  in  the  resulting  shadow  of  the  bismuth  meal  must 
be  appreciated  before  we  can  diagnose  other  lesions  of  which 
the  atony  is  merely  a  complication. 

In  the  mildest  degree  of  atony,  so  frequently  met  with,  the 
food  is  held  up  for  a  short  time,  and  then  gradually  gravitates 
to  the  lowest  part ;  there  is,  however,  always  some  evidence 
of  the  tubular  formation  remaining,  even  after  a  prolonged 
period.  In  marked  cases  the  food  straightway  gravitates  to 
the  lowest  part,  and  it  is  only  the  lowest  border  that  is  out- 
lined. The  picture  of  a  really  atonic  stomach  as  seen  upon 
the  screen  shows  that  the  bismuth  meal,  instead  of  being  held 
up  in  tubular  form,  sinks  at  once  to  the  lowest  point,  where  it 
lies  as  in  a  sac.  The  whole  bismuth  meal  quickly  finds  its 
level  in  the  lowest  part,  forming  a  more  or  less  crescentic 
shadow  low  down  in  the  abdomen,  and  in  extreme  cases  even 
on  a  level  with  the  pubes. 

In  such  cases  it  is  often  difficult  to  persuade  the  patient  to 
take  more  than  a  very  small  quantity  of  the  bismuth  food, 
but  if  he  can  be  prevailed  upon  to  do  so,  it  is  found  that  the 
increased  capacity  is  obtained  by  an  increase  in  the  vertical 
depth  of  the  shadow.  In  other  words  the  stomach  does  not 
contract  upon  its  contents  but  appears  to  remain  inert. 

The  manner  in  which  the  food  enters  the  stomach  suggests 
that  the  walls  of  the  upper  part  are  in  contact,  i.e.,  it  flows 
down  in  a  thick  stream.  Sometimes,  at  the  junction  of  the 
middle  and  the  upper  third,   the  stream  breaks  off  in  thick 

*  Strictly  speaking  atony  should  be  considered  with  the  normal  stomach  for 
it  is  a  defective  physiological  action  rather  than  a  pathological  condition. 


Fiat.  15. 


Fig.  16, 


Fie.  17. 


Fig.    15.     Diagram    of    bismuth    food     entering    a    stomach    that    already 
contains  food  or  fluid,  possibly  secretion. 

Fig.  16.      Diagram  of  food  entering  an  empty  atonic  stomach.     The  shaded 
area  represents  the  collapsed  walls  as  I  imagine  them  to  be. 

Fig.  17.      Diagram    of    food    entering    an    atonic    stomach    which    already 
contains  food. 


Atony  31 

'blobs'  which  drop  to  the  lowest  point,  like  tar  falling 
through  water,  showing  that  there  is  already  some  food  in 
the  lower  part  of  the  stomach  keeping  the  walls  apart,  and 
through  which  the  bismuth  food  sinks. 

Fallacies  in  the  diagnosis  of  atony. 

That  the  bismuth  shadow  only  outlines  the  lowest  part  of 
the  stomach  after  a  time  does  not  necessarily  indicate  loss  of 
tone,  for  it  must  be  remembered  that  the  stomach  itself  will  be 
secreting  juice,  which,  being  lighter  than  the  bismuth  food, 
will  consequently  rise  above  it.  Hence,  although  the  tubular 
form  may  be  maintained,  yet  the  upper  part  of  the  tube  will 
throw  no  shadow,  because  it  contains  none  of  the  bismuth 
mixture,  for,  as  I  have  already  said,  there  is  no  churning 
action  in  the  stomach  except  close  to  the  pylorus. 

For  the  same  reason  an  atonic  condition  is  suggested  when 
the  stomach  already  contains  food;  the  bismuth  mixture 
rapidly  sinks  through  the  stomach  contents,  which  cannot  be 
seen,  and  hence  only  the  lower  border  is  outlined.  The  fact 
of  a  full  stomach  is  always  suggested,  however,  before  the 
bismuth  food  is  given  by  the  shape  of  the  air  space,  bounded 
below7  by  the  upper  margin  of  the  fluid.  Also,  when  the 
bismuth  food  enters,  it  passes  down  more  rapidly  than  when 
canalizing  a  passage  between  the  collapsed  walls,  and  in  a 
manner  that  at  once  suggests  a  heavy  substance  falling 
through  a  lighter.  Moreover,  when  a  considerable  quantity 
has  been  given,  the  shadow  indicates  that  it  is  only  the  lower 
part  of  a  column  that  we  see,  and  further  information  on  this 
point  is  easily  obtained  by  pressing  the  stomach  contents 
upwards. 

The  lowest  border  of  the  stomach  is  well  below  the 
umbilicus  in  atony,  but  this  is  no  proof  that  the  stomach  is 
atonic,  for  the  whole  organ  is  displaced  when  the  diaphragm 
is  below  its  usual  level.  This  condition — visceroptosis — is 
most  important,  as  it  gives  rise  to  severe  gastric  symptoms  in 
some  cases. 

In  a  certain  number  of  cases  where  we  find  the  lowest 
border  of  the  stomach  far  below  the  umbilicus,  the  tonic  action 


\l 


32  Gastric  and  oesophageal  affections 

appears  to  be  quite  good.  This  condition  is  known  as 
gastroptosis,  and  it  is  said  by  Goldthwaite*  that  faulty  posture 
is  the  chief  factor  in  its  production.  Certainly  it  can  be 
greatly  improved  by  abdominal  massage  and  exercises  that 
tend  to  increase  the  normal  lumbar  concavity,  as  I  have 
proved  on  several  occasions. 

It  is  a  condition  that  places  the  gastric  peristalsis  at  con- 
siderable disadvantage.  Since  the  plyorus  is  well  above  the 
lowest  part  there  is  a  tendency  towards  retention  of  food  in 
the  stomach,  which  in  its  turn  will  lead  to  a  constant  strain 
on  the  tonic  action,  and  if  this  gives  way,  the  lower  border 
falls  still  further  with  the  result  that  there  may  be  delay  in 
emptying. 

Moreover,  the  transverse  colon  is  attached  to  the  lower 
border  of  the  stomach  by  the  transverse  mesocolon,  and  it 
follows  that  in  these  cases  this  portion  of  the  large  intestine 
is  also  found  below  the  usual  level.  It  is  seldom  that  the 
ascending  and  descending  colon  have  any  mesentery  and  con- 
sequently there  is  a  tendency  to  kinking  of  the  large  intestine 
at  both  the  splenic  and  hepatic  flexures,  although  I  am  not 
convinced  that  it  actually  occurs.  As  these  patients  appear 
to  suffer  from  constipation  it  is  probable  that  mechanical 
obstruction  may  plav  a  part,  and  Goldthwaite  believes  that 
this  condition  with  its  resulting  constipation  is  the  cause  of 
many  diseases,  such  as  rheumatoid  arthritis.  He  records 
most  encouraging  cases  in  support  of  the  treatment  by 
massage  and  exercises.  In  extreme  cases  he  advises  a  short- 
circuiting  operation. 

Frequently  at  operations  the  stomach  which  has  appeared 
at  the  #-ray  examination  to  be  quite  normal  is  found  as  a 
large  flaccid  sac,  and  vice  versa.  My  explanation  of  this 
discrepancy  is  that  nausea,  disgust,  and  fear,  bring  about 
relaxation  of  tonic  action,  i.e.,  the  stomach  will  tend  to  become 
a  large  atonic  sac,  whereas  I  have  always  found  that  in  the 
act  of  retching  or  vomiting  it  is  contracted  up.  Anaesthetics 
inhibit  the  action  of  the  involuntary  muscle  of  the  stomach, 
and  consequently  the  condition  found  at  the  operation  is  that 
*  Goldthwaite.     "Boston  Med.   and   Surg.   Journal,"    1904   and  May.  1906. 


Pig.  18.     Radiogram  of  a  case  of  extreme  atom   in  which  ib<-  lowewl 

part  of  the  s( ach  extended  nearly  fi"  below  the  umbilicus.      \  little 

rood  has  just  been  given,  and  is  seen  extending  from  the  cardiac  orifice 
to  the  mass  of  food  in  the  lowest  part.  Note  how  this  is  held  np  to  some 
extent  in  the  upper  pari  by  the  walls  of  the  stomach  being  in  apposition. 
(a)  air,  (b)  cardiac  orifice,  (c)  food  sliding  down,  d)  a  peristaltic  wave 
showing  as  a  feeble  concavity  in  the  shadow,  and  (e  the  mass  of  food  in 
the  lowest  part,  (x)  umbilicus. 


Fig.   19.      Radiogram  of  an  atonic  stomach.       Pressure  has  been 

applied  to  the  abdomen  so  that  the  food  lias  been  forced  upwards.  The 
photo  was  taken  as  the  food  was  again  taking  up  it>  position  in  the 
lower  part  and  shows  the  distribution  of  the  rugae  in  parallel  lines 
coinciding  with  the  axis  of  the  stomach.  (a]  air,  tin  food  held  up 
between  the  collapsed  walls  and  passing  down  through  the  rugse  to  the 
mass  of  food,  (c);-  (a)  umbilicus.  A  suspension  of  bismuth  was  used  to 
obtain  this  result. 


Pyloric  obstruction  33 

in  which  the  muscle  happened  to  be  when  the  anaesthetic  adr-d 
upon  it,  and  is  a  mosi  unreliable  index  to  the  natural 
condition. 

PYLORIC  OBSTRUCTION. 

Obstruction  is  a  relative  term  and  depends  not  only  on  the 
narrowing  of  the  canal  through  which  the  food  has  to  pass, 
but  on  the  vis  a  tergo.  These  are  the  two  main  factors,  but 
when  the  stomach  is  atonic  there  is  also  the  static  disability 
resulting  from  the  fact  that  the  lowest  part,  in  which  the  food 
collects,  is  far  below  the  pylorus. 

It  seems  impossible  at  present,  even  with  detailed  notes  of 
all  these  84  cases  before  me,  to  analyse  with  certainty  the 
various  stages,  as  I  have  done  in  the  case  of  oesophageal 
obstruction— the  part  that  loss  of  tonic  action  plays  is  so 
difficult  to  determine.  In  the  large  majority  the  loss  of  tone 
is  a  marked  feature,  but  in  a  small  number  perfect  tonic  action 
persists  in  spite  of  the  most  striking  retention,  hardly  any  of 
the  bismuth  food  having  passed  on  in  24  hours.  Apart  from 
these  rare  cases,  which  I  shall  refer  to  later,  the  stages  are  not 
so  difficult  to  separate,  although  there  is  no  definite  dividing 
line  between  them  :  — 

A.  In  acute  cases. 

(1)  It  is  very  seldom  that  a  really  acute  case  is  seen.  I 
have  only  seen  two,  but  in  both  of  these  the  writhing 
and  twisting  of  the  stomach  in  its  efforts  to  pass  the 
food  out  was  a  sight  that  is  not  readily  forgotten. 
In  both  of  them  it  was  a  carcinoma  of  the  plyorus 
that  was  the  cause  of  the  trouble.  The  struggle 
seems  to  be  over  in  a  short  time  and  the  picture 
becomes  that  of  a  chronic  obstruction  in  its  third 
stage,  but  whether  under  type  1  or  type  2  I  cannot 
tell. 

B.  In  chronic  cases. 

Type  1.     (1)  A  normal  stomach  that  exhibits  rather  active 

peristalsis  persistently  and   yet  shows   no  signs    of 

emptying  in,  sav,  three-quarters  of  an  hour.     Such 

a  picture  is  rather  suggestive  of  slight  obstruction 

D 


34  Gastric  and  oesophageal  affections 

but  far  from  diagnostic.  In  a  certain  number  of 
these  cases  hypersecretion  has  been  noted.  (See 
P.  37-) 

(2)  A  normal  stomach  that  occasionally  shows  very  powerful 

waves  (or  successions  of  waves)  of  peristalsis  with 
periods  of  inactivity  between,  is  suggestive  that 
peristaltic  action  is  becoming  worn  out,  and  if  this 
sign  is  observed  on  one  or  two  occasions  it  is  practic- 
ally certain  that  obstruction  is  present.  I  have  seen 
such  peristalsis  entirely  checked  both  by  tr.  bella- 
donnas and  sodium  bicarbonate,  but  the  action  of 
neither  of  these  drugs  is  constant  in  this  respect. 

There  may  be  some  delay  in  emptying  but  it  is 
seldom  as  long  as  six  hours.  These  are  the  cases 
most  frequently  met  with  in  private  practice  and  that 
give  most  trouble  in  diagnosis. 

(3)  Retention  of  food  is  found  when  the  peristalsis  fails  to 

empty  the  stomach,  and  the  patient  nearly  always 
complains  that  he  feels  his  '  food  lying  on  his 
stomach  '  for  hours.  Tonic  action  is  called  into 
play  continuously,  for  the  stomach  is  never  empty, 
and  by  degrees  the  organ  becomes  atonic.  Owing 
to  the  failure  of  tone,  the  stomach  becomes  stretched, 
the  muscle  is  thinned  out  and  cannot  produce  peris- 
taltic waves  of  the  same  power  as  formerly.  Not 
only  so,  but  the  work  it  is  called  upon  to  do  in  lifting 
the  food  to  the  pylorus  increases  as  the  greater 
curvature  sags  down  towards  the  pelvis.  Even 
when  the  stomach  becomes  quite  atonic,  its  lowest 
border  sometimes  as  low  as  the  symphysis  pubis,  I 
have  very  seldom,  if  ever,  failed  to  see  evidence  of 
peristalsis,  provided  the  apparatus  was  working 
efficiently.  In  one  of  these  atonic  cases  I  found  quite 
a  quantity  of  bismuth  food  in  the  stomach  five  days 
after  it  had  been  given,  in  spite  of  persistent  vomit- 
ing. (Figs.  18  and  20) 
Type  2.  I  have  no  evidence  whether  or  not  the  early 
stages  in  these  cases  are  the  same  as  in  type  1,  but 


Fig.  20.  Radiogram  of  a  typical  case  of  chronic  pyloric  obstruction, 
Type  1.  The  plate  was  taken  '21  hours  after  the  food  was  given,  and 
the  bismuth  is  seen  lying  about  5  inches  below  the  level  of  the 
umbilicus.  None  of  the  food  appears  to  have  reached  the  caecum.  .\ 
little  more  food  has  been  given  and  can  be  seen  sliding  down  between 
the  collapsed  walls  of  the  upper  part  of  the  stomach.  The  radiogram 
does  not  happen  to  show  any  of  the  "  blobs "  of  bismuth  food  falling 
from  this  point  into  the  lower  part  of  the  stomach. 

X  is  the  position  of  the  umbilicus. 


Fig.  21.  Radiogram  of  Type  2  of  pyloric  obstruction.  The  plate 
was  taken  24  hours  after  the  bismuth  food  had  been  given  and  none 
of  the  food  seems  to  have  left  the  stomach.  Note  the  perfect  tonic 
action,  the  absence  of  peristalsis,  the  wide  column  of  fluid  above  the 
bismuth  shadow  and  the  fluid  line  forming  the  lower  margin  of  the 
air  shadow.       X  is  the  position  of  the  umbilicus. 


Pyloric  obstruction  35 

the  resulting  «-ray  picture  is  a  mosl  striking  contrast. 

Perfect  Ionic  action  is  always  present  and  yet  the 
stomach  is  invariably  full  of  fluid,  and  presumably 
this    fluid    is    food.        Peristalsis    is    entirely    absent, 

or   there    mav    be    an    occasional    powerful    wave. 

The  delayed  emptying  is  just  as  marked  as  in  the 
atonic  cases,  and  on  examining  the  operative  findings 

I  see  that  out  of  eight  cases,  six  showed  carcinoma 
of  the  pylorus  (20,  31,  80,  309,  682,  698),  while  of  the 
two  others  one  (208)  is  reported  as  an  extensive  ulcer 
of  the  lesser  curvature  close  to  the  pylorus,  and  the 
other  (313)  showed  marked  cicatricial  contraction,  the 
pylorus  being1  one  mass  of  fibrous  tissue;  precisely 
similar  lesions  were  found  in  some  of  the  atonic 
cases.     Fig.  21  is  a  good  example  of  this  type. 

In  the  latter  stages  then,  pyloric  obstruction  gives  rise  to 
retention  of  food,  and  the  diagnosis  rests  on  the  determination 
of  this  fact.  The  detection  of  retained  food  in  the  stomach 
when  the  bismuth  examination  is  made  is  of  some  importance 
and  will  therefore  be  considered. 

If  the  tone  of  the  stomach  is  good  we  can  see  a  broad  fluid 
line  below  the  air,  which  ripples  and  splashes  when  the 
patient  is  shaken,  even  though  he  has  been  starved  for  several 
hours  previously.  On  giving  bismuth  food  a  stream  of  dense 
shadows  is  seen  falling  from  the  cardiac  orifice  down  to  the 
lowest  part  of  the  stomach — like  pitch  dropping  through 
water.  Naturally,  only  the  lower  border  is  outlined,  and  on 
giving  more  food  it  is  noted  that  the  shadow  suggests  that  the 
bismuth  is  only  indicating  the  lower  part  of  the  vertical  column 
of  the  stomach  contents.  The  peristaltic  waves  are  sometimes 
excessive  and  when  we  see  very  powerful  waves  that  are 
followed  by  a  period  of  inactivity  it  is  practically  certain  that 
obstruction  is  present,  but  of  course  all  such  observations 
must  be  confirmed. 

When  the  tone  of  the  stomach  is  defective  the  retained 
food  sinks  to  the  lower  part  and  there  is  nothing,  except  the 


36  Gastric  and  oesophageal  affections 

way  in  which  the  food  drops  to  the  lowest  part  (see  fig.  17, 
p.  30),  to  indicate  the  presence  of  the  retained  food.  The 
picture  is  simply  that  of  an  atonic  stomach  in  which  peristalsis 
is  more  violent  than  one  would  expect  in  a  thinned-out  organ. 

Retention  of  bismuth  food  is  the  result  of  pyloric  obstruc- 
tion and  Rieder  laid  it  down  that  the  whole  of  a  bismuth  meal 
should  have  left  the  stomach  within  five  hours.  For  diagnostic 
purposes  this  is  a  good  enough  guide,  but  I  never  report 
definite  obstruction  unless  the  delay  is  well  marked.  In 
hospital  practice  eight  hours  retention  is  my  standard,  but, 
in  the  vast  majority  of  the  cases  recorded,  some  food  was  still 
present  in  the  stomach  after  24  hours.  In  private  practice 
six  hours  is  my  standard,  but  I  always  repeat  the  observation 
on  at  least  one  occasion  to  verify  this  finding  when  the 
margin  of  delay  is  so  small.  It  is  quite  possible  that  in  the 
early  stages  there  may  be  rapid  emptying  as  was  noted  in 
case  126  in  which  an  operation  nine  months  later  showed 
quite  well  marked  pyloric  obstruction. 

Bad  teeth  and  septic  conditions  of  the  mouth  must  be 
attended  to  before  any  reliance  can  be  placed  on  these  data. 
I  have  seen  a  case  cured  by  removal  of  carious  stumps  in 
which  quite  a  large  quantity  of  food  was  still  present  in  the 
stomach  after  24  hours. 

Notes  on  Cases  of  Pyloric  Obstruction. 
(Cases  on  p.  89.) 

The  large  number  of  cases  that  fall  under  this  head  is  most 
striking.  In  84  out  of  270  cases  included  in  this  tabulation, 
pyloric  obstruction  was  verified  by  the  operative  findings. 

No  attempt  has  been  made  to  separate  out  the  malignant 
cases  from  the  non-malignant,  as  so  large  a  number  were  on 
the  border  line,  and  nothing  but  a  microscopic  examination 
would  have  determined  the  cause  of  the  obstruction.  As  yet, 
the  #-ray  examination  reveals  the  mere  fact  of  obstruction, 
and  does  not  give  any  definite  clue  as  to  the  nature  of  the 
lesion  except  when  a  portion  of  the  gastric  cavity  is  obliterated 
— such  cases  have  been  tabulated  in  Class  5.  From  the 
surgical  point  of  view,  however,  the  nature  of  the  disease  is 


Hypersecretion  37 

of  secondary  importance  ;is  compared  with  the  knowledge 
that  there  is  obslruclion  present  and  that  the  patient  can 
almost  certainly  he  relieved,  for  a  time  at  any  rate,  no  matter 
what  the  cause  may  be.  It  is  worthy  of  note  in  this  conne 
tion,  that  in  some  cases  that  were  undoubtedly  malignant,  the 
patient's  general  condition  improved  in  a  manner  that  was 
quite  as  striking  as  in  the  non-malignant  cases.  Not  only 
so  but  the  patients  have,  in  one  or  two  instances,  been  in 
perfect  health  when  enquiry  was  made  six  months  and  even 
two  years  later. 

The  large  number  of  instances  of  spasmodic  and  organic 
contractions  of  the  body  of  the  stomach,  in  connection  with 
pyloric  obstruction,  is  discussed  on  p.  46. 

HYPERSECRETION. 

I  have  met  with  a  number  of  cases  in  which  all  the  appear- 
ances of  a  normal  stomach  were  present  but,  after  perhaps  a 
quarter  of  an  hour,  all  the  bismuth  food  occupied  the  lower 
part  of  the  stomach,  while  the  upper  part  contained  nothing 
but  thin  fluid — the  gastric  secretion.  Such  a  picture  indicates 
excessive  secretion,  and  in  the  few:  cases  that  have  been  sub- 
mitted to  operation  an  ulcer  near  the  pylorus  has  been  found. 
The  marked  acidity  of  these  excessive  secretions  is  very  readily 
demonstrated  by  giving  sodium  bicarbonate  and  watching 
the  rapid  increase  of  the  air  space  in  the  fundus.  The  active 
secretion  cannot  be  detected  when  there  is  atony.  Fig.  15 
represents  the  appearance  seen  when  secretion  is  very 
excessive. 

Notes  on  Ulcers  of  the  Pyloric  Region. 
(Cases  on  p.  84.) 

The  pars  pylorica  contains  comparatively  little  of  the 
bismuth  food  at  a  time  and  its  shadow  is  therefore  not  so  easy 
to  see  as  that  of  the  large  mass  in  the  body  of  the  stomach. 
Moreover,  the  opacity  of  the  vertebral  column  is  superimposed 
and  renders  it  almost  impossible  to  make  certain  of  details. 
As  yet,  I  have  never  seen  a  case  in  which  I  obtained  any 
definite  evidence  of  ulceration  from  the  appearance  of  the  pars 


38  Gastric  and  oesophageal  affections 

pylorica  itself,  but  there  are  several  signs  that  point  towards 
the  presence  of  an  active  ulcer  in  this  region.  There  is  no 
hard  and  fast  line  between  the  cases  of  ulceration  with  spasm 
and  those  of  organic  obstruction  of  the  pylorus,  and  in  the 
following  list  of  cases  I  have  included  only  those  in  which 
there  was  either  no  really  excessive  peristalsis,  no  delay  in 
emptying,  or  no  marked  cicatrization  of  the  pylorus  found  at 
the  operation. 

In  some  of  the  earlier  cases  no  indication  of  any  patholo- 
gical condition  was  recognised.  Most  of  these  have  remained 
in  their  original  class  (Class  iv),  i.e.,  under  ulcers  of  the  body 
of  the  stomach.  It  is  only  recently  that  I  have  made  the 
observation  that  hypersecretion  can  be  easily  detected  radio- 
graphically.  The  number  of  cases  that  have  been  operated 
on  so  far  is  comparatively  small,  but  in  those  cases  where 
this  phenomenon  was  well  marked  the  operative  findings  have 
shown  active  ulceration  close  to  the  pylorus.  Unfortunately 
there  are  degrees  of  hypersecretion,  and  in  the  less  marked 
cases  the  sign  certainly  does  not  necessarily  indicate  ulcera- 
tion ;  moreover,  the  ulceration  of  malignant  disease  will  give 
rise  to  the  same  sign.  At  the  present  time  I  am  investigating 
this  subject  and  have  found,  as  expected,  that  on  neutral- 
ising the  secretion  with  a  solution  of  sodium  bicarbonate, 
there  is  apparently  a  far  less  profuse  liberation  of  C02  in  the 
carcinomatous  cases  than  in  those  which  are  probably  due  to 
ulceration.  Although  the  number  of  cases  is  rather  small  I 
have  now  little  hesitation  in  suggesting  a  diagnosis  of  pyloric- 
ulceration'  if  : — (i)  the  stomach  is  normal,  (2)  the  peristalsis  is 
rather  active,  (3)  no  shadows  are  seen  passing  through  the 
duodenum,  (4)  there  is  very  rapid  secretion  which  gives  off 
COa  freely. 

It  will  be  noted  that  the  picture,  as  stated,  differs  widely 
from  that  seen  in  duodenal  ulceration,    (p.  54.) 


39 


CHAPTER  VI. 

GASTRIC  ULCER  AND  HOUR-GLASS  STOMACH. 

(Organic  and  spasmodic.) 

(i)  Ulcers  of  the  fundus  of  the  stomach  are  rare  but  two 
cases  that  I  examined  came  i<>  the  post-mortem  room.  ( )n<- 
was  a  small  cicatrized  ulcer  about  two  inches  from  the  cardiac 
orifice  on  the  anterior  wall,  the  other  a  malignant  ulceration 
of  the  fundus  that  did  not  involve  the  cardiac  orifice.  In  both 
of  these  cases  the  only  symptom  noted  at  the  time  of 
examination  was  oesophageal  obstruction  and  in  both  there 
was  very  marked  distension  of  the  lower  end.  In  one 
of  them  a  large  quantity  of  bismuth  food  remained  in  the 
oesophagus  and  was  found  there  24  hours  later  and  this  in 
spite  of  the  fact  that  the  patient  had  been  'vomiting'  and 
that  at  the  post-mortem  there  was  no  trace  of  obstruction  or 
of  any  pathological  change  at  the  cardiac  orifice  itself.  I 
think  it  is  highly  probable  that  many  of  the  cases  of  'cardio- 
spasm '  recorded  by  Plummer*  and  others  are  in  reality  due 
to  ulcers  near  the  cardiac  orifice. 

(2)  Ulcers  of  the  pylorus  give  rise  to  spasmodic  contraction 
of  the  pylorus.  The  actual  obstruction  in  some  cases  is  so 
marked  and  so  persistent  that  the  stomach  may  become 
completely  atonic,  extending  to  4  or  5  inches  below  the 
umbilicus,  while  only  a  very  small  quantity  of  the  food  is 
passed  out  in  24  hours.  Later  on  the  ulceration  leads  to 
cicatrization  but  as  yet  the  .r-ray  method  does  not  yield  us 
any  information  as  to  the  importance  of  one  or  other  factor 
in  the  production  of  the  obstruction.  In  a  few  cases  of 
active  ulceration  close  to  the  pylorus  one  has  noted  very 
marked  and  rapid  secretion  of  gastric  juice,  which  is  very 
easily  detected  as  it  lies  above  the  bismuth  food.     (See  p.   37.) 

*H.  S.  Plummer,  "Journal  of  American  Medical  Association.''   August.  19US 
and  June.  1910;  J.  S.  Mayer,  ibid.,  October.  1910. 


40  Gastric  and  oesophageal  affections 

(3)  An  ulcer  of  the  body  of  the  stomach  is  nearly  always 
in  an  irritable  condition  and  as  a  result  it  gives  rise  to 
a  spasmodic  contraction  of  greater  or  less  severity,  the 
effect,  radiographically,  being  an  hour-glass  appearance  that 
can  only  with  difficulty  be  distinguished  from  the  cicatricial 
hour-glass  to  which  it  ultimately  gives  rise. 

That  the  stomach  is  an  exceedingly  sensitive  muscular 
organ  is  evidenced  by  the  frequency  with  which  spasmodic 
conditions  are  met  with,  quite  apart  from  organic  lesions, 
while  it  is  very  rare  to  meet  with  any  active  ulcerative 
condition  that  is  not  complicated  by  a  spasmodic  element  that, 
from  the  functional  point  of  view,  is  of  far  greater  importance 
than  the  actual  lesion  itself.  For  instance  a  small  ulcer  of 
the  greater  curvature  may  cause  an  hour-glass  contraction 
that  prevents  the  food  passing  into  the  lower  part  of  the 
stomach  as  in  cases  207,  389,  400  and  406  where  a  gastro- 
jejunostomy had  failed  to  relieve  the  symptoms. 

The  contractions  of  the  stomach  most  frequently  met  with 
are  about  the  junction  of  the  middle  and  upper  third,  and  the 
picture  given  by  the  bismuth  meal  is  that  the  food  descends 
to  this  point  and  assumes  a  cone  shape.  Comparatively 
suddenly  the  spasm  may  relax  and  the  bismuth  food  passes 
on  into  the  lower  portion,  often  in  a  thick  stream,  giving  a 
somewhat  bilocular  appearance  for  a  time. 

When  the  bismuth  food  is  held  up  in  the  upper  portion  of 
the  stomach  I  have  found  that  rubbing  the  abdomen  very 
frequently  relaxes  the  spasm  so  that  the  contents  pass  down 
at  once.  When  the  tone  of  the  whole  organ  is  good  the 
resultant  shadow  is  that  of  a  normal  stomach  with  possibly 
a  small  indentation  to  mark  where  the  spasm  had  occurred; 
but  if  the  tone  is  defective,  as  is  common  in  these  cases,  the 
contents  drop  into  the  lower  part,  possibly  leaving  a  small 
quantity  at  the  point  where  the  obstruction  was  noted. 
Further  abdominal  massage  usually  causes  the  whole  shadow 
to  gravitate  to  the  lowest  part,  but  if  traces  are  observed  for  a 
considerable  length  of  time,  in  spite  of  massage  and  a  drink 
of  milk,  it  is  practically  certain  that  there  is  definite  ulceration 
or  cicatrization  at  this  point  giving  rise  to  the  spasm.     The 


U.S. 


..L  S. 


Fig.  22. 


' 


P.U. 


L.S. 


Fig.  24. 


Fu 


Fig.  22  Radiogram  of  typical  upper  sac  of  an  hour-glass  stomach. 
This  was   a   cicatricial   hour-glass   stomach. 

Fig.  23.  Hour-glass  stomach.  U.S.  Upper  sac.  L.S.  Lower  sac. 
0.   Passage  leading  to  lower  sac. 

Fig.  24.  Radiogram  of  an  hour-glass  stomach.  Massage  made  no 
impression.  Note  the  small  pocket  to  the  inner  side  of  outlet  from  the 
upper  sac  {P.U.)  :  this  is  one  of  the  penetrating  ulcers  described  by 
Haudek.  (L.S.)  Indicates  the  lower  sac.  Extensive  cicatrization  of 
the  stomach  forming  a  very  typical  hour-glass  contraction. 

Fig.  25.  Hour-glass  stomach  is  often  associated  with  pyloric  obstruc- 
tion. The  bismuth  food  is  passing  through  the  channel  and  falling  in 
drops  through  the  retained  food  in  the  lower  sac. 


Gastric  ulcer  and  hour-glass  stomach  41 

more  persistent  the  spasm  in  spile  of  massage,  the  more 
probable  becomes  ihe  diagnosis  of  actual  ulceration  or 
cicatrization.  Acute  pain  on  deep  pressure  al  the  site  oi  the 
constriction  is  very  suggestive  of  the  presence  of  an  ulcer. 

In  .-i  certain  proportion  of  cases  small  pockets  are  formed 
by  chronic  penetrating  ulcers,  as  pointed  out  by  rlaudek,4 
and  these  often  hold  their  bismuth  food  for  quite  a  long  time 
after  the  rest  of  the  food  has  passed  on  (fig.  24).  In  one 
patient  1  examined  recently  I  found  a  verv  marked  p"<  kel 
on  the  lesser  curvature  (fig.  26).  There  is  no  doubt  that  it  was 
due  to  a  chronic  penetrating  ulcer  although  the  patient  had  no 
gastric  symptoms  at  all.  The  interesting  point  in  this  case 
is  that  the  patient  had  no  gastric  symptoms  probably  because 
the  ulcer  did  not  give  rise  to  any  spasmodic  contraction,  i.e., 
it  was  not  irritable.  On  the  other  hand  I  saw  a  case  in  which 
only  a  few  ounces  of  food  could  be  forced  into  the  stomach, 
forming  a  small  funnel-shaped  shadow,  and  after  24  hours  all 
this  bismuth  food  was  still  in  the  same  position.  This  patient 
was  operated  on  and  there  was  nothing  abnormal  to  be  noted 
about  the  stomach  except  a  fairly  large  ulcer  high  up  on 
the  greater  curvature  that  was  threatening  to  perforate. 
There  was  no  cicatrization. 

These  two  extreme  cases  indicate  the  importance  of  the 
spasmodic  contraction  resulting  from  ulceration,  and  all  my 
observations  on  this  subject  strongly  support  Hertz's  views 
on  the  subject  of  pain  due  to  gastric  ulcer:  "  I  believe  that 
tension  is  the  only  cause  of  true  visceral  pain."f  The 
importance  of  examining  while  symptoms  are  present  is 
obvious. 

Belladonna  has  a  marked  influence  on  some  of  the  spas- 
modic contractions.  Relaxation  ma}-  be  startlingly  sudden  in 
some,  while  in  others  no  effect  is  noted,  although  the  massage 
test  has  proved  the  condition  to  be  spasmodic.  In  a  very 
marked  hour-glass  contraction,  which  was  thought  to  be 
partly  organic,  I  found  that  this  drug  practically  removed  the 
obstruction  between  the  upper  and  lower  parts  of  the  stomach. 

*M.  Haudek,  "Arch,  of  the  Rontgen  Ray,"  June.  1911. 

I-  A.  F.  Hertz,  "The  Sensibility  of  the  Alimentary  Canal."  1911.    p.  47. 


42  Gastric  and  oesophageal  affections 

Acting  on  the  suggestion  of  this  examination,  one  patient  has 
lived  in  perfect  comfort  for  the  past  eighteen  months,  taking 
small  doses  of  tr.  belladonnae  from  time  to  time. 

The  shape  of  the  upper  sac  in  organic  contractions  is 
nearly  always  as  in  fig.  22,  but  it  is  not  diagnostic. 

The  shape  depends  on  the  fact  that  of  the  two  curvatures 
of  the  stomach  the  lesser  is  the  more  fixed  :  consequently  any 
contraction  that  takes  place  is  towards  the  lesser  curvature. 
If  however  an  ulcer  occurs  in  some  other  part  and  produces 
adhesions,  the  site  of  the  ulcer  itself  becomes  fixed  and  the 
stomach  is  contracted  to  this  part  as  in  fig.  27  where  the  ulcer 
on  the  posterior  wall  was  adherent  to  the  pancreas. 

It  is  not  easy  in  many  cases  to  distinguish  between  a 
functional  and  an  organic  hour-glass  contraction.  In  both 
cases  the  bismuth  is  held  up  in  the  upper  sac,  and  it  may 
possibly  be  noted  that  retained  food  is  also  present  in  it.  It 
is  always  suggestive  of  a  bilocular  condition  if  the  lowest  part 
outlined  by  the  bismuth  does  not  reach  nearly  to  the  level  of 
the  umbilicus  without  showing  some  indication  of  turning  to 
the  right  as  if  towards  the  pylorus. 

On  watching  carefully  it  is  generally  seen  that  some 
portion  of  the  shadow  is  passing  on,  either  in  drops  or  as  a 
thin  pencil,  and  falling  into  the  lower  sac.  If  this  is  not  seen, 
the  patient  should  be  persuaded  to  take  some  more  of  the 
bismuth  meal,  or  a  drink  of  milk,  and  this  is  often  sufficient 
to  increase  the  intragastric  pressure,  so  that  the  passage  will 
be  canalized. 

If,  on  rubbing  the  patient's  abdomen,  it  is  found  that  the 
greater  part  of  the  shadow  descends  into  the  lower  sac,  the 
condition  is  certainly  spasmodic.  But  if  manipulation  makes 
little  or  no  difference  in  the  rate  at  which  food  leaves  the  upper 
sac,  a  true  organic  hour-glass  condition  is  probably  present. 
A  careful  examination  of  the  upper  sac  will  usually  reveal  the 
presence  of  peristalsis  on  the  greater  curvature,  starting 
almost  under  the  diaphragm — that  is  to  say,  much  higher  up 
than  usual.  I  used  to  consider  that  the  presence  of  peristalsis 
in  the  upper  sac  was  one  of  the  diagnostic  points  between  a 


Fig.  26.  Radiogram  of  an  hour-glass  stomach.  The  opening  from 
the  upper  sac  is  not  in  the  usual  position  on  the  inner  side,  but  from 
the  posterior  wall.  Pyloric  obstruction  is  also  present,  and  the  food 
seen  in  the  lower  sac  had  been  given  6  hours  previously  while  that  in 
the  upper  sac  had  only  just  been  taken.  The  condition  was  due  to  a 
very  dense  mass  of  cicatrization  adherent  to  the  pancreas  (accounting 
for  the  position  of  the  neck  of  the  hour-glass)  and  marked  thickening 
of  the  pylorus.     X  umbilicus. 


Fig.  -11.  Radiogram  of  case  referred  to  on  p.  42,  and  a  normal  stomach 
with  the  exception  of  the  pocket  on  the  lesser  curvature,  indicated  by 
the  arrow,  due  to  a  chronic  penetrating  ulcer  (Haudek).     X    umbilicus. 


Hourglass  stomach  43 

true  organic  and  ;i  spasmodic  obstruction,  but  this  is  not 
the  case. 

It  must  be  emphasized  once  again  that  there  will  be  a 
spasmodic  elemenl  in  almost  all  organu  lesions,  and  thai  the 
functional  disability  will  not  depend  so  much  on  the  lesion 
itself  as  upon  the  spasmodic  contra)  lion  to  which  it  gives  rise. 

Moreover  there  arc  occasional  cases  of  spasmodic  hour- 
glass contractions  which  give  all  the  typical  appearances,  and 
yet  at  the  operation  there  is  no  gross  lesion  to  be  found  to 
account  for  the  spasm.  I  believe  that  the  spasmodic  nature 
of  these  cases  can  be  diagnosed  if  the  massage  test  is 
thoroughly  used.  Since  I  have  employed  it  I  have  been 
misled  only  once,  although  1  have  seen  several  cases  that 
would  formerly  have  been  diagnosed  as  organic  lesions. 
The  greatest  safeguard,  however,  is  the  re-examination  of  the 
patient  on  one  or  two  other  occasions;  for  spasmodic  con- 
tractions are  not  necessarily  always  present,  whereas  organic 
contractions  can  never  completely  relax. 

In  the  lower  sac  the  food  may  show  a  variety  of  pictures, 
but  most  frequently  the  shadow  is  well  below  the  umbilicus, 
and  both  atony  and  pyloric  obstruction  are  present.  In  22 
out  of  38  cases  of  ulceration  of  the  body  of  the  stomach  there 
was  also  evidence  of  a  lesion  at  the  pylorus,    (see  p.  47. ) 

Notks  on  thf  Cases  of  Ulceration  of  thf  Body  of  thf 
Stomach.     (Cases  on  p.  85.) 

Hour-glass  Stomach. 

Ulceration  gives  an  entirely  different  .r-ray  picture  in  the 
body  of  the  stomach  to  that  seen  when  the  pars  pylorica  is 
involved,  and  I  have  therefore  separated  these  cases  from  one 
another. 

An  hour-glass  appearance  of  the  stomach  is  of  very 
frequent  occurrence,  and  in  the  early  cases  one  made  many 
mistakes  through  not  recognising  the  fact  that  the  stomach  is 
a  highly  sensitive  organ,  and  is  often  the  seat  of  spasmodic 
contractions  that  may  have  all  the  appearance  of  organic 
lesions.  It  was  onlv  when  I  discovered  that  gentle,  or  if 
necessary   forcible    massage  led  to  relaxation  of  spasm,  that 


44  Gastric  and  oesophageal  affections 

mistaken  diagnosis  from  this  cause  ceased  to  be  of  frequent 
occurrence.  Tincture  of  belladonna  was  also  employed,  but, 
although  it  relieved  the  spasm  in  some  cases,  it  absolutely 
failed  in  others.  Many  cases  of  purely  spasmodic  contraction 
have  been  met  with,  but  there  are  four  to  which  I  wish  to  draw- 
special  attention:  Class  i,  No.  369,  and  Class  viii,  Nos.  41, 
363,  and  398.  In  these  the  spasmodic  contractions  were  so 
marked  that  I  diagnosed  the  presence  of  a  definite  organic 
lesion,  while  the  operation  failed  to  reveal  any  underlying 
cause. 

Case  369.  A  marked  contraction  near  the  pylorus  that 
exactly  simulated  a  carcinoma  :  patient  only  examined  once. 
The  manipulation  of  the  stomach  at  the  operation  cured  the 
patient  and  no  trace  of  the  spasm  was  afterwards  seen  when 
he  was  re-examined. 

Cases  41,  363,  398  had  been  operated  upon  and  the  gastro- 
jejunostomy had  failed  to  relieve  the  symptoms.  In  all  of 
them  an  hour-glass  contraction  had  been  noted  before  the 
operation,  and  no  trace  of  biloculation  or  ulcer  had  been 
found  to  account  for  it,  and  when  re-examined  after  the 
operation  the  same  appearance  was  noted.  All  these  patients 
either  vomited  or  retched  while  under  observation  and  it  was 
evident  that  it  was  because  of  the  biloculation,  for  as  soon  as 
all  the  food  had  passed  down  into  the  lower  sac  this  tendency 
to  vomit  ceased  and  the  pain  became  less  severe. 

The  most  searching  scrutiny  of  the  outside  of  the  stomach 
failed  to  reveal  any  abnormality,  although  I  think  it  probable 
that  some  minute  erosion  or  irritable  point  must  have  been 
present.  In  another  case  (Class  vi,  No.  713),  at  which  only  one 
examination  was  possible  before  the  operation,  I  found  a  very 
marked  hour-glass  in  association  with  an  early  stage  of 
pyloric  obstruction.  In  this  case,  although  no  lesion  could 
be  found  to  account  for  the  spasm,  the  patient  stated  that 
relief  of  his  '  hunger  pain  '  (a  typical  description)  occurred  as 
the  food  canalized  the  'middle  sphincter.'  I  quite  expect  to 
find  that  this  patient  is  not  cured  by  the  gastrojejunostomy.* 

*  See  footnote  on  p.  65. 


Hour-glass  stomach  45 

Turning  to  the  records  in  whirl)  .'i  definite  ulcer  or  evident  e 
of   old   ulceration    was    found,    I    have    in    the    following    list 

tabulated  42  cases,  and  in  38  <>f  them  the  lesion  was  indicated 

radiograph ically  by  the  hour-glass  appearance  that  was  due 
in  part  to  cicatrization,  but  to  a  greater  extent  ;is  ;i  rnl<-  to  the 
induced  spasmodic  contraction.  It  is  not  possible  to  classify 
the  findings  as  these  have  varied  widely,  from  a  little 
cicatrization  about  an  ulcer  to  a  constriction  that  completely 
divided  the  cavity,  but  the  #-ray  picture  has  almost  always 
shown  a  very  much  narrower  channel  than  was  found  at  the 
operation.  In  some  cases  this  has  been  very  marked  indeed; 
quite  a  small  ulcer  on  the  greater  curvature  with  just  a  little 
puckering  around,  has  given'  rise  to  a  contraction  so  severe 
and  so  persistent  under  massage  that  only  a  thin  stream  could 
find  its  way  down,  and,  on  the  other  hand,  a  well  marked 
cicatricial  hour-glass  with  an  indurated  ulcer  might  relax  to 
a  great  extent  with  massage,  leaving  a  channel  that  appeared 
to  be  more  or  less  the  same  size  as  that  found  at  the  operation. 
There  was  a  greater  or  lesser  degree  of  spasm  in  all  these 
cases,  and,  so  far  as  I  can  gather  from  my  notes,  the  severity 
of  the  spasmodic  element  does  not  depend  on  the  size  of  the 
ulcer  but  rather,  one  would  suppose,  on  its  irritability.  Hence  (_ 
the  functional  disability  resulting  from  an  ulcer  of  the  body 
of  the  stomach,  apart  from  the  stenosis  of  very  marked 
cicatricial  contraction,  cannot  be  gauged  by  the  appearance 
found  at  the  operation. 

In  all  these  42  cases  there  are  only  four  in  which  an  ulcer 
of  the  stomach  failed  to  give  rise  to  a  contraction  that  was 
easily  detected  on  the  screen. 

No.  24.     Large  ulcer  of  lesser  curvature   near  pylorus — 
one  of  the  early  cases  in  which  the  pars  pvlorica  was 
not  well  seen,  and  no  records  of  secretion  or  peris- 
talsis   were  made. 
No.  193.     A  small  ulcer  of  the  lesser  curvature,  one  inch 

below  the  cardiac  orifice. 
No.  418.     Large  ulcer  of  lesser  curvature.      Cicatrices  of 

the  duodenum. 
No.  760.     Cicatrix  of  lesser  curvature,  two  inches  from  the 
pylorus. 


46  Gastric  and  oesophageal  affections 

It  will  be  noted  that  in  all  these  cases  the  ulcer  was  on  the 
lesser  curvature,  near  one  or  other  of  the  orifices. 

With  the  exception  of  these  four  cases  therefore,  ulceration 
of  the  body  of  the  stomach  has  given  rise  to  an  hour-glass 
contraction  (about  905  per  cent.). 

The  association  of  these  hour-glass  contractions  with 
pyloric  obstruction  is  very  marked.  In  14  cases  out  of  the 
38  this  condition  was  also  present,  and  it  is  probable  that  the 
four  cases  in  which  the  gastrojejunostomy  had  failed  to 
relieve  the  symptoms  (Nos.  206,  266,  389,  and  400)  should 
also  be  added  to  the  number.  Ulceration  of  the  pylorus  was 
also  met  with  in  four  cases  (Nos.  335,  599,  717,  720)  and 
presumably  these  would  eventually  have  become  cases  of 
pyloric  obstruction.  In  at  least  a  half  of  the  cases  of 
ulceration  of  the  body  of  the  stomach  therefore,  there  was  also 
a  lesion  at  the  pylorus. 

Among  the  cases  of  pyloric  obstruction  will  be  found  many 
cases  where  spasmodic  contractions  of  the  middle  of  the 
stomach  were  well  marked,  but  in  a  far  larger  number,  slight 
spasmodic  contractions  were  easily  recognised  as  such,  and 
were  not  recorded.  This  association  cannot  be  accidental, 
but  whether  both  conditions  depend  on  some  other  unrecog- 
nised condition  within  the  abdomen,  or  whether  the 
contraction  of  the  body  of  the  stomach  depends  on  the  pyloric 
lesion  I  cannot  say,  but  am  inclined  to  the  former  view. 

In  two  cases  (Nos.  418  and  420)  cicatrization  of  the 
duodenum  was  also  noted. 

In  four  cases  ((Nos.  207,  389,  400,  and  406)  a  gastro- 
jejunostomy had  failed  to  relieve  the  symptoms,  and  a  further 
operation  showed  the  presence  of  an  organic  hour-glass 
contraction  above  the  stoma ,  as  suggested  by  the  #-ray 
examination. 

CARCINOMA  OF  THE  STOMACH. 

New  growths  in  the  abdomen  throw  no  shadows  which  can 
be  distinguished  from  the  general  abdominal  opacity ;  they 
can   however  often   be   demonstrated   by  reason   of  displace- 


Fig.  28.     Carcinoma  cf  the  stomach.     The  whole  of  the  pyloric  portion 
and  a  part  of  the  lesser  curvature  are  invaded. 


Fig.  -21).  Radiogram  of  a  case  of  carcinoma  of  the  stomach.  The 
pyloric  portion  of  the  cavity  is  almost  completely  obliterated.  In  some 
cases  the  shape  of  the  remaining  cavity  is  most   irregular. 


Carcinoma  of  the  stomach  47 

ments  of  viscera,  irregularities  caused  by  the  inroads  of  the 
growth  into  the  stomach,  and  by  obsini'  tion  to  the  passage  ol 
the  food,  all  of  which  may  be  shown  by  giving  the  patient  :> 
bismuth  meal.  If  the  pylorus  is  involved,  obstruction  may 
be  noted,  but  this  form  of  obstruction  cannot  as  a  rule  be 
distinguished  from  pyloric  obstruction  due  to  other  causes. 

Apart  from  pyloric  obstruction,  the  diagnosis  of  carcinoma 
depends  upon  the  irregularities  caused  by  the  inroads  of  the 
growth. 

The  inroads  may  be  quite  small,  like  the  outline  of  a  piece 
of  coral,  or  there  may  be  more  or  less  marked  obliteration  of 
the  cavity  by  the  growth  which  displaces  the  bismuth  and 
consequently  gives  rise  to  deficiency  in  the  normal  shadow. 
Such  inroads  may  suggest  peristaltic  waves  at  first  sight,  but 
on  further  observation  it  is  noticed  that  they  are  permanent, 
and  that  peristaltic  waves  sweep  up  to  these  notches,  are  lost 
to  sight,  and  reappear  on  the  further  side  of  them.  In 
advanced  cases  the  greater  part  of  the  gastric  cavity  may  be 
completely  obliterated.     (See  figs.  24  and  25.) 

Growths  involving  the  anterior  or  posterior  walls  some- 
times invade  the  stomach  so  that  bismuth  is  displaced  and  a 
clear  space  is  seen  in  the  midst  of  the  shadow .  These  clear 
spaces  may  appear  and  disappear  as  peristaltic  waves  sweep 
past,  or  on  pressing  the  abdomen  against  the  screen,  but  they 
must  not  be  confused  with  similar  appearances  caused  by, 
say,  curds  of  milk  which  contain  no  bismuth.  This  fallacy 
is  always  guarded  against  by  making  radiograms  on  two 
successive  days  and  a  comparison  of  these  will  give  the  clue 
to  the  real  interpretation. 

Spasmodic  contractions  mav  simulate  the  appearance  of 
growths  and  therefore  massage  should  be  employed,  and  even 
if  there  is  no  doubt  a  subsequent  examination  should  be 
undertaken  for  confirmation. 

We  cannot  exclude  the  presence  of  new  growths  by  this 
method,  but  it  is  seldom  that  there  is  no  clue  to  the  diagnosis 
if  the  new  growth  actually  invades  the  stomach. 


48  Gastric  and  oesophageal  affections 

Notes  on  Cases  of  Carcinoma  of  the  Body  of  the 

Stomach.  (Cases  on  p.  88.) 
To  place  all  the  cases  of  carcinoma  of  the  stomach  under 
one  head  was  quite  impossible  as  such  a  large  number  of  the 
pyloric  cases  were  on  the  border  line,  and  in  many  cases  the 
surgeon  could  not  tell  whether  the  thickening  was  due  to 
inflammatory  causes  or  to  new  growth.  All  cases  of  pyloric 
obstruction,  whether  due  to  growth  or  cicatrization,  have 
therefore  been  placed  together  in  Class  4,  and  in  the  following 
list  are  included  only  those  in  which  the  growth  invaded  the 
body  of  the  stomach. 

In  the  diagnosis  of  carcinoma  of  the  stomach  reliance 
must  be  placed  on  the  displacement  of  the  bismuth  food  by 
the  growth.  In  the  large  majority  of  cases  a  considerable 
portion  of  the  cavity  was  involved  and  there  was  no  doubt  as 
to  the  diagnosis.  In  a  smaller  number  definite  inroads  of 
growth  were  noted,  often  difficult  to  distinguish  from  peristaltic 
waves,  especially  when  the  apparatus  was  not  working  well. 
Adhesions  in  some  cases  gave  rise  to  indentations  that  were 
mistaken  for  carcinoma,  and  in  one  case  (recorded  under 
Class  1,  No.  369)  a  pure  spasmodic  contraction  gave  rise  to 
the  same  mistake. 

An  hour-glass  appearance  is  sometimes  caused  by  the 
obliteration  of  part  of  the  cavity  (fig.  25),  and  it  may  be  difficult 
to  distinguish  a  carcinomatous  biloculation  from  the  cicatricial 
condition,  as  in  case  59,  but  when  the  growth  is  sufficiently 
advanced  to  give  rise  to  such  an  appearance,  an  abdominal 
tumour  can  almost  invariably  be  detected. 

Clear  spaces  in  the  bismuth  shadow  have  been  noted  on 
several  occasions  (case  58  is  the  only  one  in  the  tabulation, 
but  in  my  notes  I  have  records  of  eight  such  observations  in 
patients  whose  clinical  symptoms  left  no  room  for  doubt  as 
to  the  diagnosis).  The  chief  source  of  error  is  the  presence 
of  boluses  of  ordinary  food  or  even  curds  of  milk,  but  a 
confirmatory  examination  will  clear  up  this  point.  These 
clear  spaces  are  often  only  demonstrated  by  pressing  the 
patient's  abdomen  against  the  screen,  and  they  tend  to  appear 
and  disappear  as  peristaltic  waves  pass  over  them. 


Aerophagy  49 

The  movements  of  the  diaphragm  are  sometimes,  but  nol 
often,  restricted,  and  on  many  oc<  asions  I  have  found  the  liver 
enlarged  and  the  diaphragm  pushed  up  on  the  right  side, 
indicating   secondary   growth   in    the    liver.      In    no  single 

instance  have  I  found  secondary  deposits  in  the  lungs,  in  fad 
the  only  instance  of  this  complication    I   have  mel    with   in 

association  with  abdominal  cancer  was  in  a  case  where  I 
reported  the  stomach  as  normal  and  in  which  carcinoma  of 
the  rectum  was  subsequently  discovered. 

Twenty-three  cases  only  are  tabulated  out  of  a  much  larger 
number  in  which  the  diagnosis  has  been  perfectly  plain,  often 
both  clinically  and  radioscopically.  In  many  of  them  the 
#-ray  report  showed  that  operative  interference  would  be 
useless.  This  probably  accounts  for  the  presence  of  only  five 
cases  of  this  type  in  the  last  300  cases  examined. 

AEROPHAGY  {air-swallowing). 

Air-swallowing  is  not  an  uncommon  condition,  and  one 
which  may  give  rise  to  severe  gastric  symptoms. 

On  giving  bismuth  food  the  outline  of  the  stomach  may  be 
perfectly  normal,  or  it  may  suggest  an  atonic  condition  ;  but 
it  is  always  noticed  that  as  the  patient  swallows  his  food  a 
certain  amount  of  air  passes  down  the  oesophagus  with  each 
mouthful,  and  the  air  space  gradually  increases  and  may  even 
extend  down  even  as  far  as  the  umbilicus  unless  eructations 
occur.  The  cardiac  portion  may  be  dilated  like  a  great 
bubble,  occupying  the  whole  of  the  left  hypochondriac  region 
and  even  displacing  the  diaphragm  upwards.  Such  patients 
swallow  more  air  with  liquids  than  they  do  with  solid  or  semi- 
solid food,  so  that  any  case  where  this  condition  is  suspected 
should  be  tested  with  a  glass  of  water. 

In  well-marked  cases  violent  and  persistent  eructations 
may  take  place,  and  it  is  noted  that  the  air  shadow,  instead  of 
becoming  smaller,  remains  the  same,  or  even  becomes  greater 
in  extent.  Sometimes  the  air  distends  the  lower  part  of  the 
oesophagus  to  some  extent. 

On  more  than  one  occasion  I  have  seen  the  air  apparently 
sucked  down  the  stomach  to  the  level  of  the  umbilicus.      It 


50  Gastric  and  oesophageal  affections 

looks  as  if  this  is  only  possible  when  the  lower  part  of  the 
stomach  is  anchored  down  by  adhesions,  but  I  have  not  been 
able  to  satisfy  myself  on  this  point. 

I  have  noted  the  occurrence  of  slight  aerophagy  in  connec- 
tion with  appendicitis  on  a  considerable  number  of  occasions 
when  gastric  symptoms  were  apparently  due  to  this  cause. 

ADHESIONS.    (Cases  on  p.  95.) 

For  the  diagnosis  of  adhesions  we  have  to  depend  on 
the  fact  that  under  normal  conditions  it  is  possible  to 
manipulate  the  stomach  through  the  abdominal  wall  and  to 
determine  more  or  less  accurately  the  fixity  or  otherwise  of 
the  organ.  Some  cases  are  more  or  less  obvious,  e.g., 
adhesions  of  the  lesser  curvature  to  the  lower  border  of  the 
liver  but,  like  all  other  observations  on  the  stomach,  one  must 
repeat  the  observation  at  a  subsequent  examination,  for  on 
more  than  one  occasion  I  have  found  that  the  confirmatory 
examination  revealed  a  perfectly  normal  stomach  in  cases 
where  I  had  been  quite  confident  that  there  were  adhesions. 

In  some  cases  they  cause  inroads  into  the  gastric  cavity 
that  are  almost  impossible  to  distinguish  from  carcinomatous 
inroads,  and  in  case  699  this  mistake  was  made,  while  in 
case  408  the  stomach  was  segmented  by  a  band  of  adhesions 
near  the  pylorus  and  other  small  indentations  were  noted  that 
suggested  this  diagnosis,  although  there  was  some  doubt  in  my 
mind  as  to  whether  the  case  was  or  was  not  one  of  carcinoma. 

In  case  151  the  persistence  of  atony  (or  ?  gastroptosis),  in 
spite  of  massage  and  exercises,  led  me  to  suspect  the  presence 
of  adhesions  fixing  the  transverse  colon  in  the  pelvis,  as  it  was 
impossible  to  raise  the  stomach  by  manipulation  although  it 
could  be  pushed  sideways,  while  the  transverse  colon  appeared 
to  be  fixed.  The  operation  in  this  case  showed  the  presence 
of  an  old  appendicitis  and  a  cord-like  adhesion  to  the  trans- 
verse colon. 

POST-OPERATIVE  EXAMINATIONS.     (Cases  on  p.  96.) 

Many  patients  in  whom  a  gastrojejunostomy  has  been 
performed  have  been  examined,  but  in  this  table  are  included 
only  those  in  which  the  operation  had  failed  to  relieve  the 


Post-operative  examinations  51 

symptoms.     In  the  cases  in  which  a  cure  was  effected  I  have 
not  come  across  a  single  instance  in  which  the  stoma 
closed.    In  a  small  number,  aboul  one-quarter  oi  these  cases, 
the  bismuth   food  was  observed   passing  through  both  the 

stoma  and  the  pylorus. 

In  only  one  case  (524)  was  the  appearance  of  1  1m-  formation 

of  a  vicious  circle  noted  (i.e.,  the  continued  presence  of  a 
shadow  in  the  duodenum)  and  at  the  operation  it  was  found 
that  the  stoma  was  occluded  by  adhesions  and  the  duodeno- 
jejunal flexure  kinked.  It  seems  probable,  therefore,  that  the 
theory  of  vicious  circle  vomiting"  is  at  least  an  extremely  rare 
cause  of  failure,  since  not  a  single  instance  was  found  in  the 
cases  recorded. 

In  seven  cases  (44,  416,  470,  471,  483,  524,  530)  the  .z-ray 
examination  showed  that,  either  there  was  obstruction  of  the 
small  intestine  just  beyond  the  stoma,  or  that  no  food  passed 
through  this  opening,  and  in  each  of  these  the  operation 
showed  the  presence  of  adhesions,  the  obstruction  as  a  rule 
being  due  to  kinking. 

In  seven  cases,  although  the  stoma  was  working  perfectly, 

there  was  a  well  marked  hour-glass  condition  present,  and  in 

most  of  them  it  was  evident  at   the  x-ray    examination   that 

the  patient  vomited  from  the  upper  sac,  and  that  so  soon  as 

all  the  food  had  passed  into  the  lower  sac  the  discomfort  and 

inclination  to  vomit    passed  off.      An   exploratory   operation 

was    performed    in    six    of   these    cases    with    the    following 

results  :  — 

41.  No  cause  found  to  account  for  the  hour-glass  condi- 
tion. Patient  unrelieved,  and  still  shows  hour- 
glass condition. 

207.  Cicatrix  of  greater  curvature  with  active  ulcer,  and 
partial  organic  hour-glass. 

257.     Adhesion  (extra  gastric)  forming  hour-glass. 

266.     Cicatricial  hour-glass  with  active  ulcer. 

363.  No  cause  found  to  account  for  the  condition.  Patient 
unrelieved. 

398.  No  cause  found  to  account  for  the  condition.  Patient 
relieved  five  weeks  after  operation,  but  this  also 
occurred  after  the  previous  operation.  On  this 
occasion  the  appendix  also  was  removed. 


52  Gastric  and  oesophageal  affections 

In  one  of  the  two  cases  of  active  ulceration  the  surgeon 
noted  at  the  time  of  the  previous  operation  that  a  small  ulcer 
was  present  on  the  greater  curvature,  but  it  appeared  to  be 
so  insignificant  that  he  did  not  not  excise  it,  in  the  expectation 
that  healing  would  take  place  when  the  pyloric  obstruction 
was  relieved  by  means  of  a  gastrojejunostomy.  Remarks 
on  the  three  cases  of  spasmodic  hour-glass  condition  will  be 
found  on  reference  to  p.  44. 

In  two  cases  (209  and  357)  an  hour-glass  condition  had 
been  found  at  the  time  of  the  operation  and  the  upper  sac 
united  to  the  jejunum.  In  both  of  these  cases  pyloric 
obstruction  also  was  present  with  the  result  that  food  lodged 
in  the  lower  sac.  Excision  of  the  lower  sac  was  performed 
in  both    with  complete  relief  of  symptoms. 

In  case  419  the  stoma  was  situated  further  from  the 
pylorus  than  in  any  other  case  I  have  seen.  There  was 
marked  pyloric  obstruction  and  the  peristalsis  seemed  to 
squeeze  the  food  into  the  pars  pylorica,  and  this  appearance 
coincided  with  the  pain.  At  the  operation  a  growth  of  the 
pylorus  was  found  and  excised.  This  relieved  the  patient, 
for  a  time  at  any  rate. 

Cases  689  and  756  (entered  in  Class  6)  were  both  sent  for 
examination  because  the  symptoms  persisted,  in  spite  of  an 
operation,  at  which  it  was  said  a  gastrojejunostomy  was 
performed.  In  both  cases  the  #-ray  findings  were  most 
suggestive  of  an  ordinary  pyloric  obstruction,  and  no  trace 
of  a  stoma  could  be  seen.  At  the  operations  it  was  found  that 
no  gastrojejunostomy  had  been  performed. 

In  case  10  it  was  impossible  to  detect  the  cause  of  the  delay 
in  emptying  of  the  stomach,  which  was  almost  as  marked 
after  as  before  the  operation.  The  stomach  was  completely 
atonic  and,  with  the  inefficient  apparatus  then  in  use,  it  was 
impossible  to  make  certain  of  details  in  the  pelvis. 

In  case  594  the  stoma  was  working  perfectly,  and  no  cause 
for  the  persistence  of  symptoms  was  seen.  On  reopening  the 
abdomen  it  was  found  that  the  stomach  was  adherent  to  the 
anterior  abdominal  wall,  and  the  breaking  down  of  these 
adhesions  brought  about  a  cure. 


Incidence  of  lesions  53 

INCIDENCE  OF  LESIONS  OF  THE  STOMACH. 

Il  is  interesting  to  nolc  the  sex  incidence,  of  diseases  of  the 

stomach  as  shown  by  figures  taken  from  the  tables  included 
in  this  thesis.    The  extraordinary  preponderance  <>f  ul<<-rs  of 

the  body  of  the  stomach  in  females  is  most  marked,  almost 
5  to  i,  while  from  lesions  of  the  pylorus,  including  both  simple 
and  malignant,  the  male  sex  appears  to  suffer  most  frequently 
in  the  proportion  of  9  to  7.  The  male  sex  also  suffers  most 
frequently  from  carcinoma  of  the  stomach  (excluding  pyloric 
cancer),  in  the  proportion  of  2  to  1 . 

The  number  of  cases  is  comparatively  small  but  the  figures 
are  somewhat  striking. 


Ulcers  of  the  body 
of  the  Stomach. 

Pyloric 
Lesions. 

Carcinoma  of 
the  Stomach. 

Total - 

Male 

8       

54 

16         .... 

..        78 

Female 

•••       39       

42       . 

8       .... 

..        89 

Total  ...      47       96       24       167 

Amongst  the  cases  in  which  the  symptom  complex  of 
duodenal  irritation  was  seen  (see  p.  54,  et  seq.)  there  are 
30  males  and  only  8  females.  In  these  cases  although  the 
symptoms  were  gastric,  the  lesions  were  for  the  most  part 
secondary  or  referred.  If  these  cases  are  included  in  the 
tables  the  proportion  of  incidence  of  gastric  symptoms  is 
nearly  equal  in  the  two  sexes. 

It  would  appear  that  success  from  operative  treatment  was 
more  probable  in  men  than  in  women,  for  out  of  the  29  cases 
in  which  the  symptoms  had  recurred  or  in  which  the  operation 
had  failed  to  give  complete  relief  only  7  were  males  while  22 
were  females,  but  in  two  of  the  latter  the  subsequent  operation 
revealed  the  fact  that  no  gastroenterostomy  had  been 
performed. 


54 


CHAPTER  VII, 
SMALL   INTESTINE. 

The  food  passes  through  the  small  intestines  very  rapidly, 
it  is  squirted  through  the  pylorus  and  sometimes,  though  I 
do  not  consider  it  normal,  it  may  be  seen  going  round 
the  loop  of  the  duodenum.  The  manner  in  which  the  food 
passes  on  is  peculiar.  If  a  bolus  can  be  seen  in  the  jejunum, 
it  can  be  made  out  that  it  is  tossed  backwards  and  forwards, 
gradually  passing  onwards.  Together  with  these  peristaltic 
movements  there  is  continual  segmentation  of  the  bolus  going 
on,  so  that  almost  immediately  it  is  shredded  into  minute 
sub-divisions  and  mixed  with  the  secretions  of  digestion  to 
such  an  extent  that,  beyond  a  general  impression  of  opacity 
in  the  abdomen,  no  trace  of  the  bismuth  is  seen  until  the 
shadow  appears  near  the  caecum.  An  instantaneous  radio- 
gram, however,  will  show  the  fine  division  of  the  food  that 
has  gone  on. 

In  tubercular  peritonitis  and  other  forms  of  adhesive 
peritonitis,  I  find  that  the  segmentation  contractions,  if  one 
may  call  them  by  such  a  name,  are  defective,  with  the  result  J 
that  definite  shadows  are  seen  in  various  coils  of  small 
intestine.  Several  instances  of  lesions  of  the  jejunum  have 
been  met  with  and  in  each  of  them,  besides  the  evidence  of 
obstruction,  a  well  marked  duodenal  symptom-complex  has 
been  noted. 

DUODENAL  ULCER. 

This  condition  cannot  be  definitely  determined  by  x-ray 
examination,  but  there  is  a  symptom-complex  which  is  very 
strongly  suggestive,  if  not  of  actual  ulceration,  at  any  rate  of 
irritation  of  the  duodenum.  The  various  points  that  are 
noted  are  : — 

(i)  The  stomach  always  exhibits  good  tone,  even  if  ptosis 
is  present.     Hypertonus  is  often  noted. 


Notes  on  duodenal  cases  55 

(2)  The  peristalsis  is  more  active  than  normal,  esper  ially 
when  the  food  has  lonimciK  :cd  (o  pass  i h rough  the  duodenum. 

(3)  The  food  begins  i<>  leave  the  stomach  almost  at  once 
and  as  <-i  rule  continues  <<>  pass  out  very  rapidly  until  the 
stomach  is  empty. 

(4)  The  pyloric  relaxation  is  so  <  omplete  thai  large  masses 
of  food  arc  seen  passing  through  the  duodenum  instead  oi 
the  line,  almost  imperceptible  stream,  thai  ran  only  be 
detected  with  certainty  by  means  of  an  instantaneous 
radiogram.  In  certain  cases  a  separate  bolus  is  seen  remain- 
ing, apparently  in  a  pocket,  in  the  duodenum. 

Notes  on  Cases  of  Duodenal  Irritation. 
(Cases  on  p.  81 .) 

I  have  separated  these  cases  out  from  among  those  which 
I  had  at  first  classified  as  normal  because,  although  the 
stomach  appears  to  be  quite  normal  both  radiographically 
and  on  the  operation  table,  yet  they  appeared  to  show  certain 
radiographic  features  that  I  have  learned  to  regard  as  a 
symptom-complex.1  It  is  quite  possible  that  my  own 
technique  (i.e.,  giving  only  a  comparatively  small  quantity 
of  bismuth  food  made  with  bread  and  milk)  is  more  favourable 
for  demonstrating  this  sypmtom-complex  than  that  of  some 
other  observers,  as  one  worker  (Dr.  Thurstan  Holland,  of 
Liverpool)  has  told  me  privately  that  he  sometimes  obtains 
the  signs  I  have  described  in  perfectly  normal  subjects.  On 
the  other  hand,  Hertz2  has  arrived  at  the  same  conclusions  and 
also  Rowden,3  of  Leeds,  who  examines  Mr.  Movnihan's 
cases. 

The  symptom-complex  consists  of  the  following  signs:  — 

(1)  A  normal  stomach  but  always  more  or  less  hypertonic. 

(2)  Active  peristalsis. 

(3)  Rapid  emptying  of  the  stomach. 

(4)  Food   seen   passing  through  the   duodenum   with,    or 

without    a   persistent   shadow    in   some    part    of   the 
duodenum. 

1.  "  B.  M.  J./'  Sept.,  1910 ;  "  Archiv  Rontgen  Ray."  Oct..  1910. 

2.  A.  F.  Hertz.      "  Sensibility  of  the  Alimentary  Canal,"  1911.  p.  59. 

3.  B.  G.  A.   Moynihan.     "Lancet,"  January.  6.   1912. 


56  Gastric  and  oesophageal  affections 

(i)  The  stomach  is  invariably  4J'  shaped  and  not  a  trace 
of  atony  is  observed.  In  fact  hypertony  is  often  so  marked 
that  it  may  require  quite  a  large  quantity  of  food  to  canalize 
the  empty  stomach.  Such  cases  are  at  first  suggestive  of  an 
hour-glass  contraction,  and  in  two  of  them  (Nos.  97  and  273) 
I  actually  suspected  the  presence  of  an  organic  lesion  half-way 
down  the  stomach,  because  of  the  way  in  which  the  contraction 
of  the  walls  resisted  the  passage  of  the  food. 

The  action  of  gravity  is  an  important  factor  in  canalizing 
the  empty  stomach,  and  it  frequently  happens  that  at  the 
lowest  part  of  the  organ  there  is  a  considerable  pause  in  the 
progress  of  the  food  before  it  enters  the  pars  pylorica. 
H.  M.  W.  Gray,  of  Aberdeen,1  interpreted  this  sign  as  an 
indication  that  there  is  normally  a  sphincter  at  this  point, 
probably  indicated  by  the  incisura  of  His,  and  on  this  theory 
laid  it  down  that  the  stoma  of  a  gastrojejunostomy  should 
be  made  beyond  this  point. 

(2)  Active  peristalsis.  This  feature  is  often  not  observed 
till  the  first  food  has  entered  the  duodenum.  One  would  not 
describe  the  waves  of  contraction  as  excessive,  but,  on  the 
other  hand,  they  are  much  more  active  than  usual  and  segment 
the  shadow  perhaps  three  inches  from  the  pylorus.  Such 
peristalsis  is  seen  in  early  stages  of  pyloric  obstruction,  but 
in  duodenal  irritation  there  is  no  obstruction,  in  fact  the  pylorus 
allows  the  food  to  pass  on  more  rapidly  than  usual. 

(3)  The  rapid  emptying.  The  early  observations  I  made 
on  cases  of  duodenal  ulceration  proved  one  point  conclusively, 
namely,  that  the  stomach  began  to  empty  itself  extremely 
rapidly  and  in  a  manner  that  was  not  observed  in  the  normal 
healthy  subject.  In  some  cases  a  meal  of  half  a  pint  of 
bismuth  food  had  left  the  stomach  in  less  than  half  an  hour 
and  it  was  exceptional  to  find  more  than  a  very  small  quantity 
in  the  stomach  after  three-quarters  of  an  hour.     In  only  one 

1.  "Lancet,"  February  22,  1908,  p.  549,  and  July  25,  1908,  p.  224,  and 
December  3,  1910,  p.  1610. 


Notes  on  duodenal  cases  57 

case  (No.  (>(>)   was  any  delay   in  emptying  noted,   and   in   this 

the  duodenal  canal  was  stenosed  by  the  cicatrization.1 

Not  only  does  the  food  pass  out  rapidly  from  the  stomach 
but  il  seems  to  reach  I  he  large  intestine  in  an  extraordinarily 
short  time.     I  noted  shadows  in  the  caecum  in  half  an  hour 

in  one  case.  Il  is  likely  thai  this  activity  of  llie  whole  tract 
accounts  for  the  frequent  clinical  history  "My  food  does  not 
do  me  any  good." 

(4)  Food  seen  passing  through  the  duodenum.  In  the 
healthy  subject  I  do  not  expect  to  see  the  food  passing  through 
the  duodenum — it  leaves  the  pylorus  in  such  a  line  stream 
that  it  is  only  by  means  of  an  instantaneous  radiogram  that 
it  can  be  detected  with  certainty,  whereas  in  these  cases  one 
sees  quite  large  shadows  pass  through  the  duodenum,  and 
even  the  untrained  observer  has  no  difficulty  in  tracing  the 
progress  from  the  pylorus  to  the  duodenojejunal  flexure, 
although  from  this  point  onwards  the  sub-division  of  the  food 
proceeds  so  rapidly  that  no  trace  of  it  is  seen  on  the  screen. 
The  appearance  is  as  if  there  were  sudden  intermittent  relaxa- 
tions of  the  pylorus  that  allowed  more  food  to  pass  through 
than  the  duodenum  was  capable  of  dealing  with. 

It  is  not  after  every  peristaltic  wave  that  the  pylorus  opens 
in  this  way,  nor  is  it  necessarily  in  response  to  a  specially 
powerful  wave,  although  it  is  always  as  a  ring  of  contraction 
forces  the  food  against  the  pylorus  that  the  shadow  is  seen 
passing  through  the  duodenum.2 

1.  Although  the  food  begins  to  pass  out  rapidly  it  does  not  necessarily 
follow  that  the  stomach  is  emptied  quickly,  for  in  several  instances  there  has 
been  a  little  food  still  present  after  5  hours,  although  no  pelvic  lesion  could  be 
found  at  the  operation ;  only  the  duodenal  ulcer. 

2.  This  appearance  can  be  produced  artificially  by  giving  a  large  quantity 
of  food  rapidly,  and  on  one  occasion  I  even  obtained  distension  of  the 
duodenum,  but  this  was  in  a  patient  whose  mental  state  was  not  stable.  He 
wished  to  prove  that  his  stomach  was  abnormal,  and  although  he  had  been 
operated  on,  and  although  I  had  examined  him  previously  on  two  separate 
occasions,  he  would  have  me  make  an  observation  when  he  had  '  quite  filled  ' 
his  stomach.  He  swallowed  four  pints  of  custard  mixed  with  S  oz.  of  bismuth 
carbonate,  and  this  distended  the  stomach,  probably  causing  some  pressure 
on  the  duodeno-jejunal  flexure,  with  the  result  that  the  duodenum  also  was 
distended.  (No  constipation  or  pathological  effect  was  noted  as  the  result  of 
this  huge  dose  of  bismuth.)  Dr.  A.  C.  Jordan  recently  read  a  paper  before 
the  Electro-Therapeutic  Section  of  the  Royal  Society  of  Medicine  ("Proc. 
Roy.  Soc.  Med.,"  Dec,  1911),  in  which  he  described  kinking  of  the 
duodeno-jejunal  flexure,  and  I  believe  that  in  the  majority  of  his  cases  his 
technique  approximated  to  the  above  observation.  He  has  told  me  privately 
that  with  the  ordinary  methods  he  failed  to  obtain  the  appearances  he 
described.  In  my  list  of  cases  only  one  (No.  49S)  showed  obstruction  at  the 
duodeno-jejunal  flexure. 


58  Gastric  and  oesophageal  affections 

Where  the  ulcer  or  cicatrix  is  situated  on  the  lower  border 
of  the  first  part  of  the  duodenum,  it  is  sometimes  found 
that  there  is  a  definite  shadow  of  retained  food  in  this  position 
which  appears  to  be  almost  continuous  with  the  gastric 
shadow.  It  is,  however,  unaffected  by  the  peristalsis  of  the 
stomach.  When  gastric  peristalsis  is  well  marked,  it  forms  a 
complete  ring  towards  the  pylorus,  cutting  off  a  portion  of 
the  shadow  which  gradually  diminishes  in  size  as  the  con- 
stricting ring  passes  on,  the  food  escaping  back  into  the 
stomach.  The  shadow  of  food  retained  in  the  duodenum, 
on  the  other  hand,  is  unaffected  by  the  peristalsis,  and  is 
always  present  until  after  the  stomach  is  empty.  This  picture 
is  only  suggestive  of  duodenal  ulcer  in  one  position  and  is 
not  diagnostic,  since  it  may  be  due  to  puckering  of  the 
duodenum  from  other  causes,  such  as  carcinoma  and 
cicatricial  conditions  in  this  region,  e.g.,  cholecystitis. 

Examination  of  the  patient,  in  the  recumbent  position, 
may  demonstrate  a  similar  condition  on  the  posterior  wall  of 
the  duodenum,  and  it  is  usual  to  examine  all  these  cases  in 
the  horizontal  as  well  as  in  the  upright  position,  because  the 
passage  of  food  through  the  duodenum  can  be  better  seen 
with  the  patient  lying  down  than  when  he  is  standing  up. 

Very  frequently  a  'caput  duodeni,'  a  shadow  just  beyond 
the  pylorus,  is  constantly  noted  until  the  stomach  is  empty, 
but  this  is  not  I  think  of  pathological  significance;  it  is 
often  seen  in  cases  where  the  duodenal  symptom-complex 
is  not  present.  The  appearance  suggests  that  there  may  be, 
in  certain  subjects  at  any  rate,  a  second  sphincter  just  beyond 
the  pylorus  that  is  supplementary  to  the  pylorus  in  regulating 
the  supply  of  food  to  the  duodenum. 

Apart  from  this  'caput  duodeni,'  a  separate  shadow  seen 
in  the  duodenum  is  very  suggestive  of  the  formation  of  a 
pocket  by  spasmodic  contraction,  cicatrization,  adhesions,  or 
growth.  The  appearance  is  not  typical  of  any  one  condition. 
In  two  of  the  cases  (81  and  92)  this  feature  was  only  detected 
when  the  patient  lay  down. 
Exceptions  and  anomalies. 

In  two  cases  only  (Nos.  240  and  241)  a  duodenal  ulcer  was 


Notes  on  duodenal  cases  59 

said  to  be  present  (by  the  same  operator)  when  the  symptom- 
complex  was  not  noted,  but  case  No.  241  died  from  an  OCCtlll 
haemorrhage  a  few  days  subsequently,  and  at  the  post-mortem 
not  only  was  no  cause  found  for  the  bleeding,  but  also  there 
was  a  complete  absence  of  even  a  suspicion  of  ulceration, 
although  grey  patches  were  observed  on  the  peritoneum. 
Case  241  is  therefore  placed  under  the  normals,  while  rase  240 
remains  in  (his  class,  although  somewhat  discounted  bv  the 
post-mortem  on  case  No.  241.  Slighl  atony  was  noted  in 
only  one  case  (No.  501)  although  all  the  other  features  were 
well  marked,  while  gastroptosis  with  absence  of  all  the  features 
of  the  symptom-complex  occurred  in  case  730. 

In  all  these  cases  a  certain  train  of  appearances  was  estab- 
lished, and  on  analysis  I  found  :  — 

Duodenal  ulceration  -         -  14  cases. 

Cicatrization  of  the  duodenum  -       7      ,, 

Adhesions    about    duodenum    (gener- 
ally in  connection  with  gall-bladder)     13      ,, 

Carcinoma  in  this  region  -         -  3      ,, 

Appendicitis,  abscess  -         -        -       1       ,, 

Appendix  fixed  by  adhesions  near  to 
duodenum        -----       1       ,, 
I  used  to  record  only  the  actual  gastric  lesion  in  my  own 
notes    and    did    not    appreciate    the    possible    importance   of 
evidence  of  old  appendicitis  or  other  abdominal  inflammation 
as  a  possible  primary  cause  of  the  trouble. 

It  seems  probable  that  many  different  lesions  in  the 
abdomen  may  give  rise  to  what  I  believe  to  be  irritation  of 
the  duodenum,  and  will  give  rise  to  this  symptom-complex 
although  it  is  most  frequently  found  in  association  with  actual 
pathological  lesions  affecting  the  duodenum  itself. 

It  often  looks  as  if  the  '  duodenal  irritation  '  was  the  result 
of  some  other  lesion  within  the  abdomen  (as  in  case  658),  and 
that  the  presence  or  absence  of  actual  ulceration  was  more  or 
less  accidental.  This  is  entirely  in  accord  with  Movnihan's 
view  : — '  I  have  long  held  the  view  that  the  diseases  of  the 
stomach,  duodenum  and  gall-bladder,  with  which  the  surgeon 
deals,  are  not  primary  but  secondary.'  (Lancet,  Jan.  6,  191 2.) 
It  is  for  this  reason  that  I  have  termed  this  the  symptom- 


60  Gastric  and  oesophageal  affections 

complex  of  'duodenal  irritation,'  as  I  feel  confident  that 
further  investigation  will  prove  that  duodenal  irritation  and 
ulceration  are  generally,  if  not  always,  secondary  conditions. 

In  case  658  the  symptom-complex  was  found  in  association 
with  a  tubercular  ulcer  of  the  jejunum,  this  lesion  being 
discovered  at  the  operation  in  consequence  of  the  #-ray  report, 
while  in  a  more  recent  case  the  same  appearances  were  seen 
in  connection  with  an  early  carcinoma  of  the  jejunum  about 
twelve  inches  from  the  duodenojejunal  flexure.  This  case 
is  of  particular  interest  as  the  symptoms  were  extremely  vague, 
and  it  was  purely  on  the  x-ray  diagnosis  of  a  lesion  of  the 
jejunum  that  the  operation  was  undertaken.  Unfortunately 
the  patient  died,  from  delayed  chloroform  poisoning  it  is 
supposed,  and  the  condition  of  the  mucous  membrane  of  the 
duodenum  showed  that  there  had  been  some  general  inflamma- 
tion (duodenal  irritation)  of  which  no  trace  could  be  seen  on 
the  peritoneal  surface. 

(January  1913.)  Since  writing  the  above,  4  more  cases  of 
lesions  of  the  small  intestine  have  been  operated  on,  and  in 
each  of  them  I  had  noted  a  very  marked  duodenal  symptom- 
complex  as  well  as  the  accumulation  of  shadows  in  the  small 
intestine  resulting  from  the  obstruction  and  defective  move- 
ment caused  by  the  lesion.  I  have  also  noted  the  symptom- 
complex  several  times  in  association  with  mucous  colitis. 
In  a  recent  case  it  was  very  markedly  seen  in  a  patient  who 
had  a  mouthful  of  septic  teeth,  and  it  was  when  looking  for 
a  cause  for  the  x-ray  appearances,  which  gave  one  the  impres- 
sion of  secondary  gastric  trouble,  that  the  teeth  were  noted. 
At  the  operation  there  was  absolutely  no  evidence  of  present 
or  past  disease  to  be  found  in  the  abdomen.  It  is  also  present, 
to  some  extent  at  any  rate,  in  appendicitis,  if  the  symptoms 
are  at  all  gastric.  I  also  noted  similar  appearances  in  a  lady 
who  had  quite  severe  symptoms,  and  in  this  case  again  one 
had  the  impression  that  the  symptoms  were  secondary.  A  few 
weeks  later  the  patient  (aged  45)  developed  slight  delusions 
and  her  gastric  symptoms  disappeared. 

The  multiplicity  of  conditions  then,  in  which  duodenal 
irritation,  or  even  ulceration  is  noted,  makes  one  more  and 


Notes  on  duodenal  cases  61 

more   convinced    thai    in    the   large    majority  of   cases   the 

duodenal   (rouble  is,   in  the  first   place  at  any  rate-,  secondary. 

It  is  as  if  the  duodenal  region  were  the  storm  centre  for  the 
alimentary  tract  to  which  disturbances  in  other  parts,  or 
possibly  even  in  the  nerve  centres,  mif_dil  be  referred,  in  many 
cases  before  any  local  manifestations  had  developed. 
Another  interesting  and  suggestive  phenomenon  is  the  associa- 
tion of  spasmodic  and  organic  hour-glass  stomach  with  pylori' 
obstruction  (see  p.  46);  as  if  the  lesions  were  complementary 
the  one  to  the  other  or,  more  likely,  both  secondary  to  some 
common  cause  to  which  we  have  as  yet  not  found  the  clue. 


62 


CHAPTER  VIII. 

THE   AETIOLOGY   OF   GASTRIC   ULCER. 

The  aetiology  of  gastric  ulcer  has  always  pertained  to  the 
department  of  the  pathologist.  Unfortunately  the  pathologist 
can  only  study  the  dead  subject  and,  as  we  know,  the  stomach 
as  it  fulfils  its  functions  differs  widely  from  the  flaccid  sac  that 
we  see  in  the  post-mortem  room  or  even  on  the  operating 
table.  That  morbid  anatomy  does  not  always  give  a  true 
picture  of  the  cause  of  symptoms  has  been  indicated  on  many 
occasions  and  in  the  pages  of  this  book  there  are  references 
to  several  cases  that  bear  upon  the  point.  For  instance  on 
p.  16  a  case  of  obstruction  of  the  oesophagus  is  described  in 
which  the  patient  was  almost  dead  from  starvation  and  the 
oesophagus  was  dilated  to  a  great  extent.  Yet  the  post-mortem 
showed  no  sign  of  the  obstruction  that  had  been  almost 
complete  nor  of  the  dilatation  that  had  followed,  and  this  in 
an  extreme  case  in  which  the  bismuth  food  was  still  found  in 
the  oesophagus  after  24  hours.  Instances  of  spasmodic 
contractions  of  the  stomach  of  which  no  trace  could  be  found 
at  the  operation  are  very  numerous.  Special  note  is  made  of 
three  cases  on  p.  44  in  which  a  gastroenterostomy  had  failed 
to  relieve  symptoms  and  in  which  a  very  marked  and  persistent 
hour-glass  contraction  was  noted.  In  all  these  cases  the 
patient  vomited  from  the  upper  sac  and  it  was  evident  that  the 
hour-glass  contraction  was  the  cause  of  the  trouble,  and  yet 
no  pathological  change  could  be  found  to  account  for  abnor- 
malities that  were  causing  symptoms  which  made  life  a 
burden.  It  is  clear  that  in  many  cases  morbid  anatomy  tells 
but  half  the  tale,  that  half  which  relates  to  tissue  changes  and 
infers  that  the  functional  disturbance  is  due  entirely  to  these 
changes.  As  I  have  already  said  (p.  40)  it  is  often  the  smaller 
ulcers  (just  as  it  is  often  the  smaller  renal  calculi)  that  give 
rise  to  the  severest  symptoms.     On  the  other  hand  cases  have 


The  aetiology  of  gastric  ulcer  63 

been  m<'i  with  in  which  gross  pathological  changes  have 
certainly  been  present  in  the  stomach  wall  with  practically  no 
Symptoms.  A  chronic  penetrating  nl<<-r  is  mentioned  on 
p.  41  as  giving,  and  of  having  given,  practically  no  trouble. 
One  of  the  mosl  completely  fibrous  hour-glass  contractions  I 
have  seen  had  not  given  rise  to  very  severe  symptoms.  In 
fact  the  morbid  anatomy  docs  not  necessarily  give  the  clue  to 
the  actual  disturbance  and,  apart  from  the  patient's  symptoms, 
we  have  no  guide  to  the  functional  effects  of  a  lesion  of  the 
stomach  or  intestines  except  by  the  r-ray  method  of  examina- 
tion which  in  its  turn  has  its  own  limitations,  for  although  it 
shows  us  the  functional  results  it  is  only  by  inference  that  we 
diagnose  the  underlying  cause,  attempting  to  separate  the 
factors  of  spasm  and  morbid  process  that  have  produced  the 
effect. 

It  was  while  reading  the  final  proofs  of  this  book  that  the 
ideas  embodied  in  this  chapter  forced  themselves  upon  me. 
The  interpretation  of  the  pathology  of  the  living  assumed  an 
importance  that  I  had  not  previously  attached  to  it,  even 
though  I  was  so  fullv  conscious  of  the  importance  of  the 
spasmodic  element  as  a  complication  of  organic  lesions.  And 
this  is  just  the  crux  of  the  whole  argument.  At  the  operation 
one  saw  a  small  ulcer  of  the  stomach  whereas  at  the  .r-ray 
examination  one  had  seen  a  typical  and  persistent  hour-glass 
contraction  which  must  necessarily  have  been  spasmodic. 
One  took  it  for  granted  that  it  was  cause  and  effect,  the  ulcer 
being  the  cause  and  the  spasmodic  contraction  the  effect 
produced.  And  vet  on  looking  back  one  found  cases  where 
we  had  the  effect  apparentlv  without  the  cause,  the  spasmodic 
contraction  without  ulceration,  and  it  was  this  that  set  me 
thinking  that  perhaps  cause  and  effect  had  been  confused  and 
that  possibly  the  ulceration  was  the  effect  of  the  spasm  and 
that  the  spasm  was  due  in  the  first  place  to  some  other  cause 
although  it  could  also  be  produced  by  the  ulceration. 

It  was  not  a  case  of  evolving  a  theorv  and  setting  to  work 
to  prove  it ;  the  hypothesis  forced  itself  upon  me  and  it  was 
simply  a  case  of  analvsing  the  various  impressions  that  have. 
I  believe,  opened  up  the  solution  of  a  problem  that  I  had  no 


64  Gastric  and  oesophageal  affections 

thought  of  investigating.  It  is  hardly  likely  that  my  observa- 
tions cover  the  whole  of  the  ground,  but  I  am  fully  convinced 
of  the  accuracy  of  the  deductions  as  far  as  I  have  been  able 
to  carry  them  during  the  few  weeks  that  have  elapsed  since 
I  arrived  at  this  new  conception  of  their  significance. 

The  observations  on  which  the  deductions  are  based  are 
as  follows  : — 

(i)  The  stomach  is  very  sensitive  and  many  cases  of 
spasmodic  contraction  have  been  met  with  ranging  from  those 
that  were  readily  relaxed  by  massage  to  contractions  that  were 
actually  mistaken  for  organic  lesions.  Quite  a  large  number 
of  spasmodic  hour-glass  stomachs  have  been  examined  and 
found  at  operation  to  show  no  trace  of  ulceration  or  other 
abnormality  that,  by  local  action,  would  cause  the  spasm. 
These  spasmodic  contractions  have  been  met  with  in  the  body 
of  the  stomach  and  also  at  the  pylorus.  On  several  occasions 
I  have  seen  that  the  vomiting  took  place  from  the  upper  sac 
and  as  soon  as  the  food  passed  down  the  tendency  to  vomit 
and  the  pain  ceased.  They  are  often  present  one  day,  absent 
the  next ;  they  can  usually  be  relaxed  by  massage  or  manipula- 
tion to  some  extent  and  are  not  necessarily  found  at  subsequent 
examinations.  There  is  no  pain  over  the  site  of  the  spasm  on 
deep  palpation. 

(2)  Identical  contractions  have  been  met  with,  in  fact  are 
almost  invariably  met  with,  in  association  with  even  quite 
small  ulcers,  and  I  have  always  believed  that  the  severity  of 
the  spasm  resulting  from  an  ulcer  was  dependent  on  its 
irritability  and  not  on  the  size  of  the  ulcer  since  small  lesions 
gave  just  as,  if  not  more,  marked  contractions  than  the  large 
florid  ulcerations. 

(3)  I  have  seen  pyloric  obstruction — as  indicated  by  seeing 
the  greater  part  of  the  food  still  in  the  stomach  after  24  hours — 
permanently  curedby  removing  bad  teeth(p.  36).  In  an  out-patient 
with  many  decayed  stumps  practically  the  whole  of  the  food 
was  still  present  in  the  stomach  after  24  hours.  On  admission 
he  was  made  to  use  a  tooth  brush  and  when  I  examined  him 
a  few  days  later  practically  all  the  food  had  passed  out  of  the 
stomach  in  five  hours.     He  was  a  fairly  intelligent  man  and 


The  aetiology  of  gastric  ulcer  65 

had  tried  careful  dining  before  he  was  admitted  to  the  hospital 
with  no  effect. 

(4)  In  two  cases  I  have  been  so  much  impressed  by  the 

irritable  appearance  of  the  stomach  that,  in  spin-  of  fairly 
well-marked  clinical  evidence  I  reported  that  I  though!  the 
symptoms  were  secondary,  the  condition  of  the  teeth  being  in 

my  opinion  sufficient  to  cause  the  radiographic  appearances 
noted;  this  in  spite  of  the  fact  thai  some  retention  of  food  was 
noted  on  one  occasion.  In  neither  of  these  cases  was  any 
evidence  found  at  the  operation  of  gastric  or  other  intra- 
abdominal lesion  of  any  kind. 

(5)  An  irritable  condition  of  the  stomach,  or  even  an  hour- 
glass contraction,  is  frequently  noted  when  there  is  severe 
constipation. 

(6)  Spasmodic  contractions,  forming  hour-glass  stomachs 
have  been  noted  as  being  not  so  marked  or  entirely  absent 
after  the  bowels  have  been  moved  in  cases  of  severe 
constipation.1 

(7)  In  taking  brief  clinical  histories  of  approximately  1400 
cases  I  have  been  struck  with  the  frequency  of  a  history  of 
constipation  and  also  by  the  presence  of  bad  teeth  or  a  history 
of  having  had  bad  teeth  removed  after  the  onset  of  the 
symptoms. 

(8)  In  fully  a  half  of  the  cases  of  ulceration  of  the  body 
of  the  stomach  there  was  also  evidence  of  retention  of  food 
behind  the  pylorus  and  in  the  large  majoritv  of  these  latter 
there  was  actual  thickening  of  the  pylorus.  In  two  cases  in 
which  no  thickening  of  the  pylorus  was  detected  at  the  opera- 
tion a  gastrojejunostomy  to  the  upper  sac  failed  to  cure  and 
a  subsequent  examination  showed  the  bismuth  retained  in  the 
lower  sac.     A  further  operation  showed  well-marked  thicken- 

1.  Case  713,  quoted  on  p.  44,  is  instructive  in  this  respect.  There  was  a 
very  marked  hour-glass  condition  in  association  with  pyloric  obstruction. 
Nothing  was  found  to  account  for  the  hour-glass  contraction,  but  the  pylorus 
was  thickened  and  therefore  a  gastroenterostomy  was  performed.  I  expected 
that  this  patient  would  not  be  cured,  but  a  year  later  he  writes  :  "  I  have 
put  on  two  stone  in  weight  and  can  eat  everything.  I  was  always  very 
costive,  in  fact  I  never  had  a  motion  without  opening  medicine,  but  have  never 
had  a  dose  since  the  operation."  In  the  light  of  other  cases  it  looks  as  if  the 
operation  had  relieved  the  constipation  and  that  this  was  the  cause  of  the 
spasmodic  hour-glass  contraction. 


66  Gastric  and  oesophageal  affections 

ing  of  the  pylorus,  and  excision  of  the  lower  sac  cured  the 
patient. 

(9)  In  a  very  large  number  of  the  cases  of  pyloric  obstruc- 
tion a  more  or  less  marked  spasmodic  contraction  was  noted 
in  the  bodv  of  the  stomach.  The  relationship  between  spasm 
or  even  ulceration  of  the  bodv  of  the  stomach  and  pyloric 
obstruction  is  so  marked  that  it  can  hardly  be  accidental.  I 
have  often  remarked  that  it  looked  far  more  as  if  lesions  in 
these  two  sites  were  dependent  on  some  common  cause  than 
on  one  another. 

(10)  Moynihan  put  into  words  a  belief  that  had  gradually 
been  taking  shape  in  my  own  mind — "  the  diseases  of  the 
stomach,  duodenum,  and  gall-bladder,  with  which  the  surgeon 
deals  are  not  primary  but  secondary"  (Lancet,  Jan.  6,  1912). 
I  had  been  much  impressed  by  what  I  called  the  inter- 
dependence of  abdominal  conditions,  e.g.,  when  one  found 
an  irritative  condition  of  the  large  bowel,  e.g.,  mucous  colitis, 
one  usually  found  the  appearances  and  often  the  symptoms 
of  duodenal  ulcer,  while  in  one  case  there  was  a  gastric  ulcer 
with  hour-glass  contraction.  The  duodenal  appearances  and 
symptoms  were  also  noted  in  several  cases  of  lesions  of  the 
small  intestine  (carcinoma,  tubercular  ulcer  and  adhesions)  in 
which  the  actual  site  of  the  disease  was  indicated  to  the 
surgeon  solely  by  the  #-ray  examination.  In  one  of  these  a 
typical  ulcer  of  the  duodenum  was  also  found,  while  in 
another,  who  died  a  few  days  after  the  operation,  the  mucous 
membrane  was  injected  and  inflamed  although  there  was  no 
evidence  of  this  on  the  peritoneal  surface.  In  appendicitis, 
when  there  were  gastric  symptoms,  these  same  appearances 
indicating  duodenal  irritation  were  also  noted  from  time  to 
time  at  the  #-ray  examination. 

(11)  The  excessive  and  rapid  formation  of  gastric  secretion 
has  been  noted  in  all  the  later  cases  in  which  a  pyloric  ulcer 
has  been  found,  except  those  in  which  marked  retention  of 
food  was  also  present,  this  feature  making  it  impossible  to 
detect  the  hypersecretion.  Well-marked  hypersecretion  has 
been  noted  in  cases  where  there  was  slight  delay  in  emptying 
(six  hours),  and  under  medical  treatment   not  only  has  the 


The  aetiology  of  gastric  ulcer  67 

delay  in  emptying  disappeared  but  also  no  hypersecretion 
could  afterwards  be  detected.     The  hypersecretion  seems  to 

be  the  accompaniment  of  pyloric;  lesions  and  disappears  with 
the  pyloric  "  irritation."  I  have  not  yet  seen  hypersecretion 
in  association  with  an  ulcer  of  the  body  of  the  stomach  unless 
there  was  an  actual  lesion  of  the  pylorus  also  present.1  In 
one  instance  I  found  what  was  evidently  the  upper  sac  of  an 
hour-glass  contraction  of  cicatricial  type,  and  during  the  half- 
hour  I  had  the  patient  under  observation  (the  surgeon  was 
waiting-  to  operate)  only  a  very  small  quantity  of  food  found 
its  way  through  into  the  lower  sac  but  there  was  profuse 
secretion  into  the  upper  sac  and,  as  suspected,  this  indicated 
an  active  ulcer  of  the  pylorus.  At  the  operation  there  was 
only  a  very  narrow  channel  connecting  the  upper  and  lower 
sacs  so  that  the  secretion  must  have  been  poured  out  from 
the  cardiac  end,  suggesting  very  strongly  that  the  hyper- 
secretion of  pyloric  ulcer  is  a  general  secretory  activity, 
probably  reflex,  and  not  a  local  hypersecretion  dependent  on 
the  direct  irritation  of  the  ulceration.  Whether  the  pyloric 
lesion  is  the  result  of  the  hypersecretion  or  vice  versa  one 
cannot  say,  but  I  suspect  that  they  are  both  dependent  on  a 
common  cause  and  not  necessarily  on  one  another. 

(12)  In  operations  for  gastric  and  duodenal  ulcer  there  is 
very  frequently  evidence  of  old  appendix  trouble. 

(13)  Gastric  symptoms — the  old  symptom-complex  of 
gastric  ulcer— have  been  cured  by  short  circuiting  the  large 
intestine  in  a  case  of  severe  constipation.  (Lancet,  February 
8,  1913.     Paris  correspondent.) 

(14)  My  own  personal  experience  of  oral  sepsis  indicates 
that  this  is  always  worse  when  I  am  run  down  and  improves 
as  soon  as  I  take  a  holiday.  Occasionally  when  I  am  below 
par  I  have  acid  risings  into  my  mouth,  probably  indicating 
an  excessive  formation  of  gastric  juice  such  as  I  have 
frequently  noted  in  association  with  pyloric  ulcer  in  marked 
cases,  with  "pyloric  irritation"  in  the  less  marked  cases. 

1.  If  the  stomach  is  emptying  rapidly  one  has  not  the  same  chance  of  detecting 
the  presence  of  hypersecretion. 


68  Gastric  and  oesophageal  affections 

On  two  occasions  I  have  been  conscious  of  retention  of 
food  for  a  prolonged  period  and  once  I  actually  brought  up  a 
mouthful  that  contained  fragments  taken  on  the  previous  day. 
A  more  thorough  and  persistent  use  of  an  antiseptic  mouth 
wash  relieved  this  unpleasant  symptom  within  the  course  of  3. 
couple  of  days. 

Occasionally  I  am  also  troubled  with  slight  hunger  pain. 

I  am  certain  I  do  not  suffer  from  any  gastric  lesion  for  I 
have  perfect  digestion  in  the  ordinary  course  of  events  and  do 
not  know  what  indigestion  is  nor  does  the  radiographic 
examination   reveal  any  abnormality. 

(15)  The  experimental  production  of  gastric  ulcer  in 
animals  shows  that  these  always  tend  to  heal  very  rapidly  and 
a  typical  chronic  ulcer  has  not  yet,  I  believe,  been  produced, 
even  by  causing  local  thrombosis. 

(16)  I  know  that  there  is  considerable  literature  on  the 
subject  but  I  have  seen  no  case  in  which  ulceration  has  taken 
place  at  the  site  of  a  gastro-enterostomy ;  and  yet  at  this  point 
the  mucous  membrane  is  comparatively  roughly  joined,  and 
one  would  certainly  expect  that  if  ulceration  was  caused  by 
the  action  of  the  gastric  juice  this  would  be  a  very  common 
sequence  to  the  operation,  especially  when  we  remember  that 
in  most  of  the  operations  a  clamp  is  used  that  must  produce  a 
certain  amount  of  bruising.  This  is  certainly  not  the  case 
in  the  hospital  with  which  I  am  connected1  and  it  is  incon- 
ceivable that  the  mucous  membrane  is  brought  into  perfect 
apposition  in  every  case. 

(17)  In  the  duodenum  the  conditions  do  not  appear  to  be 
exactly  the  same  as  in  the  stomach.  Observations  show 
that  in  every  case  of  duodenal  ulcer,  and  also  where  there  is 
duodenal  irritation,  the  stomach  begins  to  empty  itself  very 
rapidly  and   one   can    easily    see    quite    large    shadows   pass 

1.  Neither  the  pathologist  nor  any  of  the  surgeons  at  the  Manchester  Royal 
Infirmary  have  seen  a  single  case  of  ulcer  occurring  at  the  site  of  the  stoma 
(gastro-jejunal  ulcer)  nor  have  they  seen  a  jejunal  ulcer.  The  only  case  of 
ulceration  occurring  in  this  region  was  an  acute  ulcerative  process  that  almost 
separated  the  jejunum  from  the  stomach,  but  this  was  four  years  after  the 
operation  had  been  performed. 


The  aetiology  of  gastric  ulcer  69 

through  the  duodenum.  In  some  cases  there  is  a  separate 
bolus  persistently  present  in  some  p-i n  .-is  if  ,-i  pocket  was 
formed  but,  in  spiic  of  large-  quantities  passing  through,  I 
have  very  seldom  observed  obstruction,  and  whenever  this 
has  been  seen  there  has  been  definite  cicatrization  or  some 
external  cause  found  at  the  operation  to  account  for  the 
retention.  1 1  seems  therefore  as  if  spasm,  as  seen  in  the 
stomach,  is  not  associated  in  the  same  way  with  duodenal 
ulceration  and  I  think  i(  likely  thai  some  Other  influence  is  at 
work  in  these  cases.  'The  conditions  thai  obtain  in  the 
Stomach  and  duodenum  during  life  are  as  yet  only  partly 
understood  and  the  various  factors  that  control  the  passage 
of  the  food  through  the  pylorus  are  by  no  means  clear.  I 
have  given  my  reasons  (p.  26)  for  believing  that  the  control 
of  the  pylorus  is  influenced  by  the  duodenal  condition.  In 
all  cases  of  duodenal  ulcer  and  of  duodenal  irritation  one  sees 
very  abnormal  pyloric  relaxation  as  evidenced  by  the  passage 
of  large  masses  of  food,  whereas  in  the  normal  subject  it  is 
practically  impossible  to  see  the  food  passing  through  the  duo- 
denum, so  fine  is  the  stream  that  passes  through  the  pylorus, 
and  so  rapid  the  segmentation  and  shredding  of  the  food.  The 
appearances  suggest  that  the  segmentation  contractions  that 
normally  shred  the  food  in  the  small  intestine  are  absent  in 
the  duodenum  when  there  is  ulceration  or  irritation,  otherwise 
the  large  shadows  would  not  be  seen  in  the  duodenum.  We 
know,  therefore,  that  the  pylorus  is  abnormally  relaxed  in 
these  cases  and  one  suspects  that  the  relaxation  extends  to 
the  duodenum  and  that  the  relaxation  is  sufficient  to  counter- 
balance whatever  tendency  towards  spasmodic  contraction  the 
ulceration  might  give  rise  to.  The  absence  of  a  spasmodic 
contraction  in  these  cases  would  account  for  the  fact  that  they 
frequently  heal  spontaneously,  but  the  causation  of  these  ulcers 
does  not  appear  to  be  the  same  as  in  gastric  ulcer. 


Taking  all  these  observations  together  I  think  that  they 
become  intelligible  on  the  following  hypothesis  :  — 

Septic  conditions  in  the  mouth  or  other  sources  of 
swallowed  septic  matter,  constipation,  mucous  colitis  and  a 
variety  of  other  conditions  are  capable  of  producing  spasmodic 


1/ 


70  Gastric  and  oesophageal  affections 

contractions  of  various  parts  of  the  stomach.  The  spasm 
produces  a  narrowing  of  the  lumen  that  is  of  great  functional 
importance,  causing  a  definite  obstruction  to  the  passage  of 
food.  By  an  indiscretion  of  diet  or  want  of  masticaton  some- 
thing too  large  to  pass  easily  through  the  channel  has  to  be 
forced  through  by  powerful  peristalsis.  This  leads  to  an 
abrasion  at  the  point  where  the  lumen  is  narrowed  and  where 
there  is  the  constant  irritation  of  food  passing  over  it.  Also 
a  surface  is  exposed  that  is  not  structurally  fitted  to  withstand 
the  action  of  the  gastric  juice.  In  this  way  an  ulcer  is  formed 
which  in  its  turn  perpetuates  the  original  spasm  that  deter- 
mined the  site  of  the  ulcer.  A  vicious  circle  is  established, 
the  ulcer  now  being  actually  the  cause  of  spasm  that  prevents 
healing  so  that  even  if  the  original  cause  of  the  spasm  is 
removed  there  is  little  if  any  improvement  in  the  local 
condition. 

The  stomach  and  duodenum  are,  as  it  were,  the  storm 
centre  for  the  alimentary  tract  to  which  peripheral  stimuli  are 
referred,  the  result  being  either  a  general  irritable  condition 
of  the  stomach  and  duodenum  or  spasmodic  contractions  of 
one  or  more  parts  of  the  stomach.  These  stimuli  are 
referred  to  the  stomach  and  duodenum  either  directly,  from 
swallowed  septic  matter,  or  indirectly  from  lower  parts  of 
the  tract  as  in  the  case  of  lesions  of  the  small  intestine  as 
indicated  radiographically  and  proved  by  operation ;  as  in 
the  mucous  colitis  cases  and  constipation  cases  as  indicated 
radiographically  and  also  by  the  subsequent  history  of 
the  cases. 

Appendix  dyspepsia  is  too  well  known  to  need  mention. 
Radiographically  it  is  indicated  as  a  rule  by  duodenal  irritation 
and  Moynihan  tells  of  the  very  large  percentage  of  duodenal 
ulcer  cases  in  which  there  is  evidence  of  old  appendicular 
trouble. 

Now  these  spasmodic  contractions  give  rise  to  all  the 
radiographic  appearances  of  actual  lesions — on  more  than  one 
occasion  a  surgeon  has  re-opened  an  abdomen  at  my  sugges- 
tion because  of  the  persistent  hour-glass  contraction  that  has 
been  noted  above  the  stoma  of  a  gastro-enterostomy  which  was 


••  The  aetiology  of  gastric  ulcer  71 

functioning  perfectly.    Three  of  these  patients  were  actually 

observed    vomiting    from    f lie    upper    sac    ol    the    hour-glass 

contraction,  the  pain  and  tendency  i<»  vomit  disappearing 
when  once  the  food  had  passed  down  into  the  lower  sac,  and 

yet  no'  cause  was  found  a!  the  operation  to  accounl  lor  the 
contraction.  In  several  cases  where  I  have  reported  definite 
pyloric  obstruction  the  surgeon  could  find  nothing  to  indicate 
gastroenterostomy,  and  in  two  of  them  a  subsequent  operation 
showed  thickening  of  the  pylorus.  There  are  many  cases  of 
various  types  all  pointing  in  no  uncertain  manner  to  the 
obvious  conclusion  that  the  spasmodic  contraction  is  of  as 
great  importance  functionally,  as  the  organic,  and  that  these 
apparently  purely  spasmodic  contractions  are  replaced  by 
actual  organic  lesions  has  been  actually  noted  in  some  two  or 
three  cases  in  which  a  second  operation  has  been  undertaken. 
(This  has  been  noted  only  at  the  pylorus  as  yet.) 

That  ulcerations  of  the  alimentary  tract  are  irritable  and 
give  rise  to  spasmodic  contractions  1  have  seen  proved  time 
and  again,  e.g.,,  ulcers  of  the  cesophagus  tiiat  only  caused 
symptoms  (and  obstruction)  after  the  patient  took  dry  bread 
crumbs.  (The  ulcers  were  actually  seen  through  the  cesopha- 
goscope  afterwards.)  The  same  has  been  noted  in  the  stomach 
very  frequently.  Hour-glass  contractions  with  retention  of 
food  in  the  upper  sac  have  often  been  found,  at  operation,  to 
be  due  to  quite  small  ulcers  with  practically  no  cicatrization. 

If  my  contention  is  correct  that  purely  spasmodic  contrac- 
tions are  capable  of  producing  functional  obstruction  which 
leads  to  trauma  of  the  mucous  membrane,  and  that  this  ulcer 
or  abrasion  is  itself  capable  of  producing  a  similar  spasmodic 
contraction,  it  follows  that  when  once  an  ulcer  is  formed  it 
will  perpetuate  the  spasmodic  contraction  even  if  the  primary 
cause  of  the  spasm  is  removed.  Hence  it  is  clear  that 
removing  the  primary  cause  will  not  cure  the  patient,  for  the 
ulcer  when  once  formed  continues  to  induce  a  spasm  that 
tends  to  the  perpetuation  of  the  ulcer.  If  on  the  other  hand 
an  ulcer  or  abrasion  has  not  occurred,  the  removal  of  the 
primary  cause  whether  it  be  teeth,  nasal  discharge  or 
swallowed  pulmonary  discharge, stagnation  of  faeces. appendix 


72  Gastric  and  oesophageal  affections 

inflammation  or  some  other  cause,  will  probably  bring  about 
a  rapid  and  lasting  cure  of  the  patient.  It  is  probable 
therefore  that  the  chief  factor  in  the  production  of  gastric 
ulcer  is  a  physical  one,  but  the  connection  between  the  various 
primary  conditions  and  the  spasmodic  contractions  they 
produce  is  a  problem  that  is  beyond  the  reach  of  radiography. 
This  theory  covers  the  whole  of  the  many  and  varied 
observations  I  have  detailed  and  I  believe  accounts  satisfac- 
torily for  them  all,  including  the  failure  to  produce  gastric 
ulcers  artificially  that  are  comparable  to  those  met  with  in  man. 
To  what  extent  the  gastric  juice  is  responsible  I  cannot  say, 
but  it  seems  reasonable  to  suppose  that  when  once  an  abrasion 
is  formed  a  surface  is  exposed  that  is  not  adapted  to  withstand 
the  action  of  the  gastric  juice  and  will  therefore  tend  towards 
the  extension  of  the  ulceration. 


73 


CHAPTER  IX. 

CONCLUSIONS. 

The  progress  thai  lias  been  achieved  in  (he  diagnosis  of 
gastric  disorders  by  means  of  I  he  bismuth  method,  has  been 
very  marked  during  (he  five  and  a  half  years  in  which  the 
material  for  this  thesis  has  been  collected.  I  have  been 
present  at  as  many  of  the  operations  as  possible,  but  have 
had  to  take  my  records  from  the  operation  books  in  a  very 
large  proportion  of  cases,  and  during  the  first  two  and  a  half 
years  the  work  was  anything  but  encouraging.  The  opinions 
I  gave  as  the  result  of  the  /r-ray  examination  were  as  often 
wrong  as  right,  and  in  many  of  the  failures  in  diagnosis  it 
seemed  that  I  was  hopelessly  beside  the  mark;  so  much  so, 
that  at  times  I  had  little  confidence  in  the  work  and  little  hope 
of  ever  becoming  successful,  the  results  were  seemingly  so 
contradictory.  During  the  next  eighteen  months,  however, 
the  apparent  inconsistencies  gradually  became  fewer  in 
number,  but  even  so  it  seemed  doubtful  if  the  results  obtained 
were  worth  the  time  and  labour  involved,  especiallv  when  one 
had  to  choose  between  this  branch  of  investigation  and  others 
which  one  knew  would  yield  satisfactory  results  if  one  had 
time  to  develop  them.  I  had  much  encouragement  from  the 
physicians  and  surgeons  of  the  Manchester  Roval  Infirmary 
and  Ancoats  Hospital,  who  have  in  this  and  other  matters 
always  been  most  helpful  to  both  my  partner,  Dr.  Bythell, 
and  myself,  when  we  have  been  carrying  out  any  work. 
During  the  last  eighteen  months  the  results  have  been  much 
more  satisfactory,  and  the  operative  findings  have  seldom 
shown  anything  that  had  not  been  indicated  by  the  .r-ray 
examination,  although  of  course  I  did  not  always  read  the 
signs  aright.  Some  of  the  failures  in  diagnosis  were  in 
connection  with  ulceration  involving  the  lesser  curvature, 
which  occasionally  seems  to  give  rise  to  no  spasmodic 
contraction ;    as  if  some  ulcers  in  this  region  were  either  not 


74  Gastric  and  oesophageal  affections 

irritable  or  interfered  with  the  nerve  fibres  that  should  set 
up  localised  spasm. 

Purely  spasmodic  contractions  have  been  another  cause  of 
failure,  but  these  have  very  seldom  given  rise  to  mistaken 
diagnosis  if  the  massage  test  was  properlv  applied,  and  if  the 
patients  were  re-examined  as  a  routine  procedure,  a  condition 
that  is  often  difficult  to  hold  to  in  hospital  practice  owing  to 
the  pressure  on  accommodation  of  the  surgical  beds. 

The  pars  pylorica  is  still  the  most  difficult  region  of  the 
stomach  about  which  to  obtain  reliable  information,  and  the 
appearances  of  this  part  very  seldom  reveal  such  details 
as  will  assist  in  the  diagnosis.  One  has  therefore  to  rely 
almost  entirely  on  the  deductive  evidence  obtained  from  the 
rate  at  which  the  food  leaves  the  stomach,  the  tonic  action, 
the  peristalsis,  secretion,  and  so  forth. 

The  point  has  not  yet  been  reached  at  which  it  is  possible 
to  say,  '  there  is  no  active  pathological  lesion  of  the  stomach 
walls  ' — one  has  so  often  to  make  reservations  as  to  the  pars 
pylorica;  but,  on  the  other  hand,  evidence  is  accumulating 
that  will  I  believe  very  soon  lead  to  the  possibility  of  always 
making  a  definite  positive  diagnosis  of  pyloric  ulcers,  and 
when  this  becomes  possible,  one  w-ill  be  able  to  give  a 
definite  negative  diagnosis  in  the  large  number  of  cases  of 
suspected  gastric  trouble  in  which  the  dyspepsia  is  functional 
or  secondary  to  some  other  trouble. 

The  certainty  with  which  pyloric  ulcers  (or,  if  one  may 
say  it,  pyloric  irritation)  may  be  distinguished  from  duodenal 
ulcers  (or  duodenal  irritation),  is  in  marked  contrast  to  the 
clinical  differentiation  of  these  cases. 

Defective  tonic  action  is  also  rather  troublesome  in)  making 
a  negative  diagnosis,  but  the  appreciation  of  the  changes 
brought  about  by  defect  of  tone  becomes  intuitive  after  a  time, 
and  I  am  now  seldom  troubled  by  the  appearances  it  causes. 

The  connection  between  the  train  of  symptoms,  which  I 
have  discussed  under  the  head  of  duodenal  irritation  (p.  55), 
with  other  lesions  of  the  intestinal  tract  is  most  striking,  and 
confirms  the  impression   that   I   took   from   A^r.   Moynihan's 


Conclusion  75 

lecture  before  the  Manchester  Pathological  Society,*  that 
duodenal  ulcer  is  probably  often  a  secondary  lesion.    As  I 

wrile   I   have  .'i   patient    under    observation  in    whom    this  ir;iin 

of  symptoms  is  well  marked,  and  the  examination  I  have  jusi 
made  (20  minutes  after  the  food  was  taken)  reveals  a  large 
collection  of  bismuth  in  the  jejunum,  and,   if  confirmed,  is 

almost  certainly  indicative  of  adhesions  or,  us  in  the  last 
similar   case,    an    ulcer   of   the   jejunum,    while   the  clinical 

evidence  only  suggests  duodenal  ulceration. 

In  taking  notes  of  all  the  cases  the  persistent  recurrence 
of  a  history  of  severe  constipation,  especially  in  women,  s<-<-m 
to  indicate  that  the  association  of  gastric  lesions  with  this 
trouble  is  more  than  a  coincidence.  In  many  cases 
chiefly  men,  the  teeth  have  been  in  a  bad  state,  sometimes 
actually  at  the  time  of  the  examination,  and  on  several 
occasions  the  cleaning  up  of  the  mouth  has  brought  about  a 
wonderful  change  not  only  in  the  patient's  condition,  but  also 
in  the  #-ray  appearances.  Cases  that  have  been  diagnosed 
clinically  and  confirmed  radiographically  as  duodenal  ulcer, 
cases  of  pyloric  obstruction  with  marked  delay  in  emptying 
and  spasmodic  contractions  of  the  stomach,  have  all  been  cured 
by  attention  to  the  teeth  and  bowels.  1  have  little  doubt  now  that 
constipation  and  bad  teeth  are  two  of  the  main  factors  in  deter- 
mining the  onset  of  ulceration  of  the  stomach  and  duodenum. 
Whether  or  not  they  are  the  actual  causes  1  cannot  say  but 
they  are  both  capable  of  giving  rise  to  spasmodic  contractions 
which  have  almost  all  the  appearances  of  pathological  changes 
in  the  stomach  walls.  One  is  more  and  more  impressed  with  the 
importance  of  the  physical  element  of  spasm,  not  only  in  the 
causation  of  true  visceral  pain  but  also  perhaps  in  the  actual 
production  of  some  of  those  lesions  of  the  alimentary  canal 
that  were  at  one  time  regarded  as  primary. 

Statistics  are  of  course  worth  very  little,  nevertheless 
I  thought  it  would  be  instructive  to  take  at  random  from  my 
files  the  records  of  thirty  consecutive  cases  and  summarise 
the  results.     In  19  I  gave  a  definite  report  that  was  entirely 

*"  Lancet."  February  24,   1912. 


76  Gastric  and  oesophageal  affections 

in  accord  with  the  operative  findings.  In  six  the  diagnosis 
was  quite  correct,  but  I  could  not  give  such  a  definite 
report,  e.g.,  suggesting  that  there  was  probably  an  ulcer  or 
growth  present,  but  that  the  £-ray  evidence  was  not  sufficiently 
definite  to  justify  the  diagnosis.  Of  the  remaining  five, 
I  find  as  follows: — (i)  a  case  of  extraordinary  extensive 
adhesions  to  the  liver,  which  I  had  diagnosed  definitely  as  a 
carcinoma  obliterating  the  gastric  cavity ;  (2)  a  case  which  I 
only  had  the  opportunity  of  seeing  on  one  occasion,  I  mistook 
a  spasmodic  hour-glass  for  an  organic  lesion,  but  also 
suggested  the  probability  of  an  ulcer  at  the  pylorus,  which 
was  found  at  the  operation  ;  (3  and  4)  in  two  cases  I  found  no 
evidence  of  ulceration,  and  the  operation  showed  the  presence 
of  an  ulcer  of  the  lesser  curvature,  in  one  case  at  the  cardiac 
end,  and  in  the  other  near  the  pylorus  (two  of  the  four 
cases  met  with  in  which  an  ulcer  failed  to  set  up  a  spasmodic- 
contraction)  ;  (5)  one  case  in  which  I  gave  a  report  that  there 
was  probably  an  ulcer  in  the  pyloric  region.  The  operation 
revealed  a  perfectly  healthy  stomach. 

There  is  no  useful  purpose  to  be  served  in  comparing  these 
results  with  those  obtained  by  clinical  methods  in  the  same 
series  of  cases,  as  the  requisition  cards  are  usually  made  out 
by  the  house-surgeons  or  house-physicians,  and  are  probably 
filled  in  at  random  before  an  exhaustive  clinical  examination 
has  been  made. 

One  conclusion  is  quite  clear ;  the  more  time  one  spends 
on  a  case  and  the  more  one  considers  the  #-ray  findings  in 
connection  with  the  clinical  history,  the  more  accurate  will  be 
the  diagnosis.  The  x-ray  method  is  of  some  value  by  itself, 
but  when  it  is  taken  in  conjunction  with  all  the  other  available 
means  of  investigation,  it  becomes  the  greatest  of  all  aids  we 
possess  in  the  diagnosis  of  diseases  of  the  walls  of  the 
intestinal  tract. 

That  the  work  is  of  value  is  evidenced  by  the  fact  that 
last  year  (191 1)  I  examined  nearly  350  in-patients  by  means 
of  the  bismuth  method  at  the  Royal  Infirmary.  But  perhaps 
the  most  noticeable  feature  is  the  fact  that  one  no  longer  hears 
of  the  successful  diagnoses  but  of  the  failures. 


77 


CHAPTER  X. 
TABULATION  OF  CASES. 

To  attempt  the  classification  and  tabulation  of  ili<-  eighl  or 
nine  hundred  cases  of  which  I  have  notes  was  obviously  a 
labour  that  would  yield  no  definite  information.  I  have 
therefore  only  tabulated  those  in  which  the  actual  condition 
was  discovered  either  on  the  operating  table  or  in  the  post- 
mortem room,  and  have  classed  them  according  to  the  actual 
pathological  lesion  found,  and  not  according  to  the  .r-ray 
findings.  Even  so,  the  task  was  not  easy,  for  there  are  many 
cases  in  which  the  operation  yields  indefinite  information  as 
to  the  exact  nature  of  the  lesion.  This  is  especially  the  case 
in  pyloric  obstruction,  and  for  this  reason  all  cases  of  this 
nature,  whether  simple  or  malignant,  are  placed  under  one 
heading. 

Again,  description  of  the  operative  findings  is  often  so 
meagre  and  so  lacking  in  detail  that  one  had  to  rely  in  many 
cases  on  the  memory  of  the  surgeon  or  house-surgeon  for 
important  information.  A  number  of  cases  have  been  rejected 
from  this  tabulation  on  the  ground  of  insufficient  data  as  to 
the  operative  findings. 

Class  1.  Cases  in  which  the  gastric  symptoms  were  not 
directly  due  to  a  lesion  of  the  stomach  or  duodenum. 

Class  2.  Cases  in  which  the  symptom-complex  of  duo- 
denal irritation  was  found,  or  in  which  an  actual 
lesion  of  the  duodenum  was  discovered. 

Class  3.     Cases  of  ulcer  of  the  pars  pylorica. 

Class  4.     Cases  of  ulceration  of  the  body  of  the  stomach 

with  or  without  the  formation  of  a  definite  hour-glass 

contraction. 

Class  5.  Cases  of  carcinoma  of  the  body  of  the  stomach — 
not  including  pyloric  carcinoma. 


78  Gastric  and  oesophageal  affections 

Class  6.  Cases  of  pyloric  obstruction — whether  simple  or 
malignant. 

Class  7.  Cases  in  which  the  stomach  was  distorted  by 
adhesions — -apart  from  actual  disease  of  the  walls. 

Class  S.  Cases  in  which  surgical  interference  had  not 
been  altogether  successful. 

I  have  added  introductory  remarks  to  each  division  with 
a  special  note  of  any  case,  or  class  of  case,  to  which  I  wished 
to  draw  attention. 

Strictly  speaking,  classes  i  and  2  should  be  under  one 
heading,  but  the  symptom-complex  of  duodenal  irritation 
seems  so  clear  that  it  will  be  readily  seen  why  these  cases  are 
classed  separately. 

The  clinical  diagnosis  is  taken  from  the  requisition  cards 
which  are  filled  up  in  the  wards. 


Tables  of  Cases 


Gastric  and  oesophageal  affections 


79 


( Ulnioal 

No.  Ako.  Sex.       Diagnosis. 


Clabs  I.    (See  p.  290 
NORMAL. 

x-ray  Binding!  np.-n.ti .,  Finding!. 


6  53  M. 


25  46  F.  ?  Carcinoma  of 
stomach. 

28  35  F.  ?  Gastric  ulcer ; 
?  carcinoma  of 
stomach. 

54  35  F.  — 

60  33  F.    ?  Carcinoma ; 

?  gastric  ulcer. 

86  35  M.  Pyloric  ulcer. 
102  22  F.     ?  Gastric  ulcer. 


125  39  F.  — 

154  40  F.  ? 

171  60  M.  Carcinoma   of 

stomach. 
182  22  M.  ? 

241  41  M.  Duodenal  ulcer. 


248  70  M.  Carcinoma. 

249  40  F.    Carcinoma   of 

stomach. 

284  25  M.  ? 

296  35  F.    Abdom.  tumour 
311  35  M.    ?  Gastric. 
333  28  F.    Gastric  ulcer. 
G 


Nil. 


Nil  when  standing;  bismuth 
segmonted  over  growth 
when  lying  down. 

Slightly  atonic  ;  nil  else. 


Nil    but  visceroptosis. 

Nil      except    slightly    active 

peristalsis. 
Excess  peristalsis ;  nil  else. 
Nil      except     rather     active 

peristalsis. 

Stomach  normal ;  nil  except 
some  air  swallowing 

Stomach  appeared  to  be 
twisted  upon  itself  ;  nil  else. 

Nil     abnormal. 

Nil    abnormal. 
Nil     abnormal. 


Nil    abnormal    found. 
Stomach  atonic  ;  some  viscero- 
ptosis. 

Normal,  except  rather  marked 

air  swallowing. 
No   abnormalities   found ;  no 

evidence  of  displacements. 
Nil    abnormal     found. 

Gastroptosis.  but  nil  else. 


.v.  e\  Idenoe  "'  ulcer. 


Carcinoma  <<\  pancreas,  etc. 
stomach  not  invaded. 

No  abnormality  found. 


Nil  in  stomach  ;  nephropexy. 
Nothing   found. 

No  evidence  of  abnormality. 

Nil  except  slight  adhesions 
near  pylorus;  no  gastro- 
jejunostomy. 

Nil     found  ;  kidneys  fixed. 

Nil      found ;     no    gastro- 
jejunostomy. 
Carcinoma  of  pancreas. 

Tubercular  peritonitis  around 
appendix. 

Surgeon  described  duodenal 
scarring,  and  patient  died 
3  days  later  from  occult 
haemorrhage  for  which  no 
cause  was  found. 

Abscess  near  appendix. 

No  abnormalities  found,  but 
gastrojejunostomy  per- 
formed. 

Appendix  removed. 

No  abnormalities   found. 

Appendix  thickened  with  ad- 
hesions. 

Nil  in  stomach :  kidneys  low 
down  :  nephropexy. 


J<-j'lh' 

did  I". t 
relieve 

rn« 


.t  DO 
better. 


Relieved. 


No  benefit. 


Patient  cured 


No  duodenal 
ulceration 
found  at 
post-mortem 


Cured. 


80 


Gastric  and  oesophageal  affections 


Clinical 
No  Age.  Sex.        Diagnosis 


X-ray  Findings. 


Operative  Findings. 


Remarks 


337  3S  M.    ?  Gastric  ulcer. 
369  44  M.  Dilat.  stomach. 


372  24  F.    Dilat.   stomach. 

398  38  F.    Dilat.  stomach  ; 

?  Gastric  ulcer. 


402  33  F. 
405  50  F. 
423  47  M. 
476  38  M. 
478  27  M. 
481  64  M. 
485  30  M. 
489  48  M. 
497  26  F. 
555  59  F. 
593a47  M. 
706  57  M. 
612  47  M. 
716  27  F. 
721  36  F. 
761  49  M. 

772  47  M. 
791  34  F. 


Gastric  ulcer. 

Dilat.  stomach. 

Carcinoma  ?   of 
stomach. 
?  Gastric  ulcer. 

Gastric   ulcer 

Carcinoma   of 
stomach. 

Gastric  ulcer  ? 
Gastritis. 

Carcinoma   of 
stomach. 

Pyloric  obstruc- 
tion. 

Duodenal  ulcer. 

Duodenal  ulcer. 

?  Gastric  ulcer ; 

?  appendix. 
?  Tumour ; 

?  gastric. 
Carcinoma   of 

stomach. 

Carcinoma   of 

stomach. 
?  Gastric  ulcer. 


Stomach  not  involved 
by  the  growth. 

Stomach  normal,  except 
marked  contraction  near 
pylorus ;  looked  like  car- 
cinoma. 

Aerophagy  ;  spasm  of  middle. 

Hour-glass  marked ;  vomiting 
from  upper  sac. 


Nil    except  active  peristalsis. 

Nil     found. 

Nil,    stomach    displaced,    but 

not  involved. 
Nil    peristalsis  rather  active. 

Nil    abnormal. 

Nil     abnormal     noted. 

Slightly  atonic. 

Nil. 

Irregular   card ;    end    looked 

like  adhesions. 
Growth  displacing  stomach. 

Nil     abnormal. 

Nil    abnormal. 

Normal. 

Gastroptosis ;  nil  else. 

Tumour  not  in  relationship  to 

stomach. 
(Esophagus    obstructed    with 

pouching ;     stomach     looks 

normal. 
Stomach  normal. 

Stomach  normal ;  rather  active 
secretion;  active  peristalsis. 


Growth  of  splenic  flexure, 
adherent  to  stomach. 

Nil  found;  no  gastro- 
jejunostomy. 


Nil    found. 

Nothing  to  account  for  the 
hour-glass ;  appendix  re- 
moved. 

Appendix    removed ;    nil    in 

stomach. 
Nil. 

Growth  of  colon. 

Nil  in  stomach;  chronic  ap- 
pendix. 
Nil;  old  appendix. 

Stone  gall-bladder. 

Appendix    removed;    nil    in 

stomach. 
Stomach    normal ;    appendix 

removed. 
Nil. 

Growth  of  gall-bladder. 

Gall-stones. 

Growth  of  pancreas. 

Few  adhesions  duodenum  to 
gall-bladder. 
Stomach     normal ;     inflamed 

appendix. 
Growth  of  kidneys ;  stomach 

not  involved. 
Stomach  normal ;  gastrostomy. 


Carcinoma  of  hepatic  flexure. 
Nil  found  in  stomach. 


Spasm 
cured  by 
laparotomy. 


Cured  5 
weeks  after 
operation, 
but  relapsed. 


Gastric  and  oesophageal  affections 


81 


Class  II.    (See  p.  55.) 
DUODENAL    IRRITATION. 

Hi/  "normal  stomach"  in  their  crises  I  mean  that  the  organ    exhibits  eithci  perfect  tonu   action  01 

'more  often  In/perlon'icx.       The  .separate  bolus  in  the  duodenum  refei     i"  the  l'i"i'  /'•',</   ./.ai/on-H  mm 
passing  through  the  duodenu/m,  not  to  the  stationary  shadow. 

Clinical 
A.g6.  Sex.         IMiiKiioHiH.  X-rny  KlmllnKH.  OpmttlT*  Finding!.  irk«. 


30  30  M.  Dilat.  stomach. 

Stomach  normal,  rapid  empty 

Adhesioni   <>i    duodenum   to 

ing;       peristalsis       active; 

liver. 

separate  bolus  in  duodenum. 

66  31  F.    Gastric  ulcer  ? 

Stomach    normal  ;     pcristalsi 

Definite  cicatrization  of  duo- 

active;   separate    bolus    in 

denum  ;     posterior     gastro- 

Cured. 

duodenum ;    stomach    emp 

jejunostomy. 

tied  rather  slowly. 

70  37  M.  Duodenal  ulcer. 

Stomach    normal ;    peristalsis 

Cicatrization       round       duo- 

Cured. 

active ;     rapid     emptying ; 

denum  ;     posterior     gastro- 

separate bolus  in  duodenum 

jejunostomy. 

78  28  M.  Tumour. 

Stomach  normal ;  rapid  empty- 

Extensive  carcinoma   not  in- 

ing,      peristalsis       active ; 

volving  stomach. 

separate  bolus  in  duodenum. 

81  51  M.  Duod.  ulcer? 

Stomach  normal ;  rapid  empty- 

Ulcer    upper     surface     duo- 

Cured. 

ing,       peristalsis       active ; 

denum. 

separate  bolus  in  duodenum, 

when  patient  lay  down. 

92  35  M.  Duod.  ulcer  ? 

Stomach  normal ;  rapid  empty- 
ing,      peristalsis       active ; 
separate    bolus    only   when 
patient  lay  down. 

Duodenal  ulcer. 

Cured. 

97  34  F.     ?  Gastric  ulcer. 

Stomach    normal;    peristalsis 

Cicatrization        about       duo- 

Much better, 

active ;      rapid     emptying ; 

denum  ;     nil     in     body    of 

but  not 

separate   bolus   in   duoden- 

stomach. 

cured. 

um  ;  spasm  middle  stomach. 

101  62  M.  Duodenal  ulcer. 

Stomach  normal ;  rapid  empty- 
ing,      peristalsis       active ; 
separate  bolus  in  duodenum. 

Duodenal  ulcer. 

Cured. 

120  56  M.  Neurosis. 

Stomach  normal ;  rapid  empty- 

Few adhesions ;   nil  else. 

Patient 

ing,       peristalsis       active : 

developed 

separate  bolus  in  duodenum. 

G.P.  1. 

184  42  M.  Duod.  ulcer  ? 

Stomach  normal ;  rapid  empty- 

Duodenal       ulcer ;        gastro- 

Cured. 

ing,       peristalsis       active : 

jejunostomy. 

separate  bolus  in  duodenum. 

218  34  M.  Duod.  ulcer  ? 

Stomach    normal ;    peristalsis 

Ulceration  both  sides  of  py- 

Relieved, 

active ;  no  separate  bolus  in 

lorus  ;   adhesions  to   liver. 

but  not 

duodenum ;  rapid  emptying. 

cured. 

219  22  M.  Gastric  ulcer? 

Stomach  normal :  rapid  empty- 

Appendicular    abscess :      ad- 

Patient not 

ing  ;  peristalsis  active ;  no 

hesions. 

cured. 

separate  bolus  in  duodenum. 

82 


Gastric  and  oesophageal  affections 


Clinical 
No.  Age.  Sex.        Diagnosis. 


X-ray  Findings. 


Operative  Findings. 


Remarks. 


240  36  M.  Dilat.  stomach. 

289  46  M.  Pyloric  obstruc- 
tion. 

307  31  F.    Stomach? 
kidneys  ? 


314  37  F.    Duodenal  ulcer. 


401  51  M. 


412  54  M.  Gastric  ulcer. 


417  54  F.    Pyloric  obstruc- 
tion. 


418  50  M.  Carcinoma. 


451  30  M.  Duodenal  ulcer. 


468  38  M.  Dilat.  stomach. 


475  37  M.  Pyloric  ulcer. 


477  35  M.  Gastric  ulcer  ? 


486  34  F.     ?  Gall-bladder. 


498  22  M.  Gastritis. 


Visceroptosis  ;    slight    atony  ; 

peristalsis  active. 
Stomach  normal ;  rapid  empty - 
■    ing ;       peristalsis       active ; 
separate  bolus  in  duodenum. 
Stomach  normal,  except  dis- 
placed ;     rapid     emptying ; 
peristalsis  active;   separate 
bolus  in   duodenum. 
Stomach  normal ;  rapid  empty- 
ing ;       peristalsis       active ; 
separate  bolus  in  duodenum. 
Stomach  normal ;  rapid  empty- 
ing ;      peristalsis      active ; 
separate  bolus  in  duodenum. 
Stomach  normal ;  rapid  empty- 
ing ;   no  active  peristalsis ; 
no   separate  bolus   in   duo- 
denum. 
Stomach  normal ;  rapid  empty- 
ing ;   peristalsis  active ;   no 
separate  bolus  in  duodenum  ; 
small  intestine  overloaded. 
Stomach      normal ;      separate 
bolus   in   duodenum ;   rapid 
emptying. 
Stomach  normal ;  rapid  empty- 
ing ;       peristalsis       active ; 
separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 
active ;  no  rapid  emptying ; 
no   separate  bolus   in   duo- 
denum. 
Stomach    normal ;    peristalsis 
active ;     rapid     emptying ; 
separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 
active ;     rapid     emptying ; 
separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 
active ;      rapid      emptying ; 
separate  bolus  in  duodenum. 
Stomach  normal ;  rapid  empty- 
ing ;       peristalsis      active ; 
separate     bolus      in     duo- 
denum ;  obstruction  at  duo- 
denojejunal flexure. 


Duodenal  ulcer. 


Growth    of   lesser    curvature. 


Adhesions  to  distended  gall- 
bladder. 


Cicatrix  round  1st  part  duo- 
denum. 


Duodenum 
not  explored. 


Adhesions 
liver. 


of    duodenum    to 


Duodenal  cicatrization. 


Adhesions  of 
liver ;  small 
examined. 


duodenum    to 
intestine   not 


Large  ulcer  lesser  curvature, 
and  duodenal  ulcer. 

Adhesion  duodenum   to   gall- 
bladder; gastrojejunostomy 

Scar    on    duodenum ;    gastro- 
jejunostomy. 

Duodenal       ulcer ;        gastro- 
jejunostomy. 

Pericholitis  ;  adhesion  to  gall- 
bladder, etc. 


Post-mortem, 
bladder. 


stone       gall- 


Pericholitis ;  duodenal  ulcer  ; 
adhesions  at  duodeno 
jejunal  flexure. 


No  indica- 
tion of  the 
gastric  ulcer. 


Gastric  and  oesophageal  affections 


83 


Clinical 
No.  Age.  Hex.        Dlagnoill, 


501  3d  M.  Gastric  ulcer. 


.r)61  27  M.  Gastric,  ulcer. 


586  40  M.  Duodenal  ulcor. 


587  23  M.  Gastritis. 


588  35  M.  Gastric  ulcer? 


589  31  M.  Duodenal  ulcer. 


613  50  M.  Duodenal  ulcer. 


619  36  M.  Gall-stones. 


638  29  M.  Dyspepsia. 


658  24  M.    ?Duod.  ulcer. 


730  49  F.    Dilat.  stomach. 


749  56  F.    Dyspepsia. 


X-ray  Bindings. 
Slight  at ;   rapid   emptying ; 

peristalsis    active  ;    hi  paral.e 

bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active;      rapid      emptying; 

separate  bolus  in  dnodannm, 
Stomach     uonnal  ;     peristalsis 

active;      rapid      emptying; 

separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active;      rapid      emptying; 

separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active ;      rapid      emptying ; 

separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active ;      rapid      emptying ; 

separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active ;     rapid      emptying ; 

bolus  in   duodenum,   which 

does  not  move  on. 
Stomach    normal ;    peristalsis 

active ;     rapid      emptying ; 

separate  bolus  in  duodenum. 
Stomach    normal ;    peristalsis 

active ;     rapid      emptying ; 

separate  bolus  in  duodenum. 
Stomach  normal ;  peristalsis 
active ;  rapid  emptying ; 
coils  of  jejunum  seen  in  left 
iliac  fossa. 
Gastroptosis ;   nil  else. 


OpsntlTc  Bindings. 


Rsmsifcs, 


'  !ii  ati  i<  ial    duodenum. 


Duodenal         ul>  «-r ;        gantro- 

jejunoftomy. 

Thickening  of   duodenum. 


Duodenal        ulcer ;        gastro- 
jejunostomy. 

Adhesions  duodenum  to  gall- 
bladder and   colon. 

Duodenal  ulcer. 


Cicatrices     of     pylorus    and 
duodenum. 


Gall-slones ;  adhesions. 


Long  appendix   fixed   by  ad- 
hesions very  high  up. 


Duodenal     ulcer     and      ring    Duodenal  ulcer 
ulcer  of  jejunum  and  ring  ulcer 

(tubercular).  of  jejunum. 

Nil  in  stomach;  adhesions  to 
duodenum. 


Stomach    normal ;    peristalsis   Gall-stones  and  adhesions, 
active ;  rapid  emptying ;  no  | 
separate  bolus  in  duodenum. 


84 


Gastric  and  oesophageal  affections 


No.  Age.  Sex. 


Clinical 
Diagnosis. 


Class  III.     (See  p.  37.) 
ULCER    OF    PYLORIC    REGION. 

X-ray  Findings.  Operative  Findings. 


Remarks. 


143  55  F.  ?  Pyloric  ob- 
struction ;  di- 
lated stomach. 

308  42  M.  Pyloric   ulcer. 


335  39  F.     ?  Gastric  ulcer. 
396  44  M.  Dilat.  stomach. 

579  40  F.    Gastric  ulcer. 
593  31  M.  Duodenal  ulcer. 

666  32  M.  Carcinoma. 
717  36  F.    Gastric  ulcer 
720  40  F     Gastritis. 


723  32  M.  Duodenum? 

appendix  ? 

724  24  M.    ?  Gastric  ulcer; 

?  carcinoma 
pylorus. 
777  32  M.  Dilat.   stomach. 


Large  atonic  stomach ;  re- 
tained food ;  no  delay  in 
passing  food  out. 

Large  atonic  stomach  with 
retained  fluid ;  no  marked 
delay  emptying. 

Hour-glass ;  secretion  into 
upper  sac ;  delay  in  empty- 
ing lower  sac  (24  hours). 

Atony ;  hypersecretion. 


Hour-glass ;  cicatrization ;  hy- 
persecretion to  upper  sac. 

Stomach  normal ;  hypersecre- 
tion ;  peristalsis  active ;  no 
food  seen  passing  through 
duodenum ;  ?  delay  empty- 
ing. 

Slight  atony ;  nil  else    noted. 

Hour-glass ;  excessive  secre- 
tion upper  sac. 

Well-marked  hour-glass ;  py- 
loric obstruction ;  rapid 
secretion. 

Hour-glass  (spasmodic)  ;  pain 
relieved  when  food  passed 
through  ;  active  secretion  ; 
active  peristalsis. 

Normal ;  active  secretion ; 
peristalsis  active. 

Stomach  normal ;  excessive 
secretion ;  active  peristalsis. 


Cicatrization    about    pylorus ; 
small  active  ulcer. 

Cicatrix   near  pylorus. 


Typical  hour-glass  stomach ; 
ulceration  and  cicatrization 
of    pylorus. 

Thickening  of  pylorus  ;  gastro- 
jejunostomy. 


'  As  though  string  had  been 
tied  round  stomach ' ;  also 
pyloric  ulcer. 

Thickening  about  pylorus  and 
lesser  curvature. 


Ulcer  posterior  wall  1  inch 
from  pylorus. 

Cicatricial  hour-glass ;  ulcer 
of  pylorus. 

Mass  of  adhesions,  middle 
lesser  curvature ;  thickened 
pylorus  with  active  ulcer; 
inflamed  appendix. 

No  hour-glass ;  no  ulcer ; 
many  adhesions  about  py- 
lorus and  ?  ulcer  pylorus  ; 
adhesions  appendix. 

Cicatrix  about  pylorus ; 
active  ulcer. 

Ulcer  pyloric  portion  on 
posterior  wall. 


Cured. 


Secretion 
into  upper 
sac. 


Hypersecre- 
tion with 
pyloric 
ulcer. 

Hypersecre- 
tion with 
ulcer  of 
pylorus. 


Rapid  secre- 
tion with 
ulcer  of 
pylorus. 


Gastric  and  oesophageal  affections 


85 


Clinical 
No,  Arc.  .Hex.     Diagnosis. 


Class  IV.     (See   p,  48.) 

ULCERATION   OF    THE    BODY    OF    THE    STOMACH. 
Houk-Glass  Contractions. 

X-ray  FlndlnKH.  Operative  KindinijH.  K*rn»rk«, 


24  50  M.    ?  Gastric  ulcer. 

Slight  delay  in  emptying;  nil 

Largo     ulcer     middle     lesser 

■   . 

else. 

curvature  ;  thickening  about 

by  gad 

pylorus. 

j'-junoHtorny. 

35  32  F.     ?  Pyloric 

Definite  hour-glass  and  pyloric 

Typical    hour-glass;    contrac- 

i by 

obstruction. 

obstruction. 

tion      and      thickening      of 

(,'astropla«ty 

pylorus. 

and  gastro- 
jejunostomy 

37  34  M.             — 

Hour-glass,  partly  spasmodic. 

Ulcer  lesser  curvature;  some 
cicatrization. 

Excised. 

79  52  M.  Gastric  ulcer. 

Spasmodic   hour-glass,    which 
relaxed  leaving  indentation. 

Ulcer  anterior  wall ;  excised. 

83  48  F.    Obstruction    of 

Definite       hour-glass       small 

Cicatricial    hour-glass ;    cica- 

Cured. 

pylorus. 

channel ;    definite   delay    in 

tricial       pylorus ;       gastro- 

lower sac. 

plasty     and      gastro-jejun 
ostomy. 

89  47  M.  Growth  ? 

Atonic     with     spasm     about 

Large    stomach ;    cicatrix    on 

Cured. 

middle. 

lesser     curvature ;     gastro- 
jejunostomy. 

91  42  F.    Pyloric 

Cicatricial  hour-glass  (funnel- 

Ulcer       greater      curvature ; 

Cured. 

obstruction  ? 

shaped)  ;  no  pyloric  obstruc- 

cicatricial  hour-glass,    with 

tion. 

adhesion. 

93  41  M.     Oesophageal 

Huge    pouching     just    above 

Post-mortem,      small       ulcer 

Xo  dilatation 

obstruction. 

diaphragm. 

anterior   surface   near   car- 

of oesophagus 

diac  orifice. 

and  no  obstruc- 
tion found 
post-mortem. 

137  42  F.    Dilatation. 

Hour-glass     stomach ;     upper 

Cicatricial  hour-glass. 

Patient  died 

sac  only  seen. 

suddenly  3 
weeks  later. 

193  59  F.    Gastric  ulcer. 

Atonic;   slight   delay   empty- 

Ulcer   1    inch    below    cardiac 

ing  ;  some  obstruction  duo- 

orifice;   ulcer   just  beyond 

denum. 

pylorus      with      cicatricial 
contraction. 

203  63  F.              — 

Hour-glass,  and  distorted  by 

Ulcers  and  cicatrices  middle 

adhesions ;     lower     sac     in 

of      stomach ;      growth     at 

right  iliac   fossa;   delay   in 

pylorus. 

emptying  of  lower  sac. 

207  30  F.    Gastric     ulcer; 

Well-marked  cicatricial  hour- 

Stomach   not    explored,    but 

Unrelieved  : 

gastrojejuno- 

glass ;   stoma  working  per- 

kidney    fixed     November. 

entered 

stomy  1908. 

fectly. 

1909. 

also   in 
Class  VIII. 

86 


Gastric  and  oesophageal  affections 


Clinical 
No.  Age.  Sex.        Diagnosis. 


X-ray  Findings. 


Operative  Findings. 


Remarks. 


207  31  F.    Same   case   one 
year  later. 

230  39  F.     ?  Stenosis  of 
pylorus. 

239  40  F.    Gastric  ulcer. 


266  43  M.  Old   gastro- 
jejunostomy. 


286  39  F.    Dilat.  stomach  ? 
gastric  ulcer. 
299  23  F.    Gastric  ulcer. 


310  40  F.    Gastric  ulcer; 
?  pyloric 
obstruction. 

331  29  F.    Gastric  ulcer. 


335  39  F.     ?  Gastric  ulcer ; 
?  carcinoma. 


364  37  F.    Pyloric  stenosis 


367  43  F.    Dilat.  stomach. 


371  39  F.    Gastric  ulcer. 

389  40  F.    Gastric     ulcer; 
old    gastroje- 
junostomy. 
400  33  F.    Gall-stone  ?  kid- 
ney ;  old  gastro- 
jejunostomy. 


Exactly  same  picture  as 
above. 

Hour-glass  stomach,  and  de- 
finite delay  in  emptying. 

Funnel-shaped  hour-glass ;  in- 
verted peristalsis  in  lower 
sac;  delay  in  emptying  (24 
hours). 

Hour-glass  stomach  well 
marked ;  stoma  working 
perfectly. 


Hour-glass  stomach ;  no  py- 
loric obstruction. 

Hour-glass  stomach,  partly 
spasmodic ;  no  pyloric  ob- 
struction. 

Hour-glass  stomach ;  definite 
delay   emptying. 


Division     of     stomach     near    Hour-glass  stomach, 
pylorus. 


Stomach    almost    divided    by 

marked  contraction. 
Ring  of  ulceration  of  greater 

curvature ;    constriction    of 

pylorus. 
Multiple    scars    forming    tri- 

locular  stomach ;  growth  at 

pylorus. 

Hour-glass,  with  active  ulcer. 


Hour-glass ;  probably  active 
ulcer. 

Large  ulcer  lesser  curvature ; 
some  puckering ;  gastro- 
jejunostomy to  upper 
pouch. 

Trilocular  stomach ;  cicatri 
cial  pyloric  obstruction. 


Cured. 


Cured  by 
gastroplasty ; 
a  small  ulcer 
of  body  had 
been  noted  at 
time  of  1st 
operation. 


Hour-glass ;      secretion      into 
upper  sac ;   delay  in  empty- 
ing lower  sac  (24  hours). 


Spasmodic  hour-glass ;  no 
pyloric  obstruction. 

Hour-glass,  chiefly  organic ; 
no  pyloric  obstruction. 

Hour-glass ;  no  pyloric  ob- 
struction. 

Hour-glass  marked ;  stoma 
patent. 

Perfect  hour-glass ;  stoma 
patent. 


Typical  hour-glass  stomach ; 
ulceration  and  cicatrization 
of  pylorus. 


Cicatricial  hour-glass,  with 
active  ulcer. 

Large ;  gastrojejunostomy 
lesser  curvature,  with  cica- 
trization. 

Hour-glass ;  gastrojejunos- 
tomy  to   lower   sac. 

Hour-glass,  with  ulcer ; 
gastroplasty. 

Cicatricial  hour-glass. 


Lower  sac 
quite  large. 

Secretion 
into  upper 
sac ;  also 
entered  in 
Class  III. 


Gastric  and  oesophageal  affections 


87 


No.  Ago.  Hex. 


Ollnical 
Dl&gnoila 


X-ray  l-'i j.-I . i.  | 


Operative  Flnrllr.KN. 


EUaafa 


406  26  P.    Old  gastro- 
jejunostomy. 
418  50  M.  Carcinoma. 

420  53  P.     ?  Stomach ; 
?  Kidneys. 
455  48  P. 

461  39  F.    Gastric  ulcer. 
465  39  F.    Gastric  ulcer. 


482  29  F.    Gastric  ulcer ; 
pyloric 
obstruction. 

490  24  F.    Dilat.  stomach. 

492  31  F.    Neurosis. 

493  45  F.    Abdominal 

tumour. 
573  18  F.    Gastric  ulcer. 

579  40  F.     ?  Gastric  ulcer. 


583  28  F.    Gastric  ulcer. 
589  39  F.    Pyloric  stenosis 
618  36  M.  Gastric  ulcer. 
686  34  F.    Gastric  ulcer? 

695  45  F.    Dilat.  stomach ; 
gastric  ulcer? 


717  36  F.    Gastric  ulcer. 
720  40  F.    Gastritis. 

760  42  F.    Gastric  ? 
kidney. 

782  65  F.    Gastric  ulcer. 


Hour-glass,  chiefly  spasmodic  ; 

stoma  patent. 
Nil;    separates    bolus    in   duo 

doiium. 

Spasmodic  hour-glass,  and 
separate  bolus  in  duodenum. 

Cicatricial  hour-glass. 

Marked   hour-glass. 

Incomplete  hour-glass;  de- 
layed emptying  lower  sac. 

Hour-glass  (cicatricial)  ;  no 
pyloric  obstruction. 

Spasmodic  hour-glass ;  delayed 
emptying  lower  sac. 

Hour-glass,  and  delayed 
emptying  lower  sac. 

Hour-glass;  no  evidence  of 
growth. 

Hour-glass ;  some  pyloric  ob- 
struction. 

Hour-glass,  cicatricial ;  hyper- 
secretion to   upper  sac. 


Spasmodic   hour-glass. 

Hour-glass,   cicatricial. 

Hour-glass,  chiefly  spasmodic. 

Hour-glass,  partly  spasmodic ; 
no  pyloric  obstruction. 

Hour-glass,  cicatricial,  pene- 
trating ulcer ;  retained  food 
(24  hours). 

Hour-glass ;  excessive  secre- 
tion upper  sac. 

Well-marked  hour-glass ;  py- 
loric obstruction ;  rapid  se- 
cretion. 

Gastroptosis :  pylorus  dropped 
2  inches ;  nephroptosis. 


Pyloric  portion  sacculated  and 
bound  to  liver;  upper 
portion  suggested  hour-glass 
contraction 


Hour  glass,  ei<  atrii  al, 

above  stoma. 
Largo  ulcer   lesser  curvature; 

cicatrix   in  duodenum. 
Hourglass      and       duodena] 

ulcer. 
Cicatricial  hour-glass. 
Cicatricial  hour-glass, 
i'yloric       obstruction  ;        old 

cicatrices  anterior  walla  of 

stomach. 
Cicatricial  hour-glass. 
Thickening  of  pylorus. 

Cicatrix  of  greater  curvature 
and  also  at  pylorus. 

Hour-glass,  adherent  to  liver  ; 
pyloric    obstruction. 

Typical  hour-glass ;  no  py- 
loric obstruction  or  growth. 

Ulcer  lesser  curvature ; 
thickened  pylorus. 

'  As  though  string  had  been 
tied  round  stomach  ' ;  also 
pyloric  ulcer. 

Large  ulcer  middle  stomach. 

Cicatricial    hour-glass. 

Ulcer  greater  curvature. 

Large  ulcer  lesser  curvature ; 
cicatrization. 

Mass  of  adhesions  middle 
stomach ;  hour-glass ;  py- 
lorus normal ;  ant«rior 
gastrojejunostomy. 

Cicatricial  hour-glass ;  ulcer 
of  pylorus. 

Mass  of  adhesions  middle 
lesser  curvature ;  thickened 
pylorus  with  active  ulcer : 
inflamed  appendix. 

Cicatricial  ulcer  lesser  curva- 
ture, 2  inches  from  pylorus. 


Hypersecre- 
tion with 
pyloric 
ulcer. 


Mass  of  adhesions  of  pyloric 
portion  stomach  to  liver; 
old  ulceration :  ulcer  of 
pylorus 


Xo  pyloric 
obstruction 
although  re 
tained  food. 
Hypersecre- 
tion with 
ulcer   of 
pylorus. 
Rapid  secre- 
tion with 
ulcer  of 
pylorus. 


88 


Gastric  and  oesophageal  affections 


Clinical 
No.  Age.  Sex.  Diagnosis. 


Class  V.     (See  p.  48.) 
CARCINOMA    OF    THE    STOMACH. 


X-ray  Findings. 


Operative  Findings. 


Kemarks. 


7  43  M.  Carcinoma   of 
stomach  ? 


8  35  M.  Carcinoma   of 

stomach. 

9  43  M.  Carcinoma   of 

stomach. 
21  45  M.  — 

40  37  M.    ?  Carcinoma. 
42  53  F.     ?  Carcinoma  of 

stomach. 
48  52  F.    Carcinoma   of 

stomach. 


58  54  M. 

64  39  M. 
170  58  M. 
233  53  F. 

289  46  M. 


297  34  M. 
300  29  F. 


342  66  F. 

366  55  F. 

380  43  M. 


?  Carcinoma  of 

stomach ; 

?  aneurism. 
?  Carcinoma  of 

stomach. 
?  Carcinoma  of 

stomach. 
?  Carcinoma  of 

stomach. 
?  Pyloric 

obstruction. 

Pyloric  ulcer. 
?  Carcinoma  of 
stomach. 

Carcinoma   of 
stomach. 

Abdom.  tumour 

Duodenal  ulcer. 


385  55  F.    Carcinoma  of 
stomach. 

403  50  M.  — 

469  66  M.    ?  Carcinoma. 

582  52  F.    Carcinoma   of 
ascending 
colon. 

614  60  M.    ?  Carcinoma  of 
pylorus. 

776  47  M.    ?  Gastric  ulcer ; 
?  pyloric 
stenosis. 


Very     excessive     peristalsis ; 
pars  pylorica  obliterated. 
No  delay  in  emptying. 


Stomach  invaded ;  small  ir- 
regular cavity  only  left. 

Inroads  of  growth  well  de- 
fined. 

Irregularity  in  outline  of 
greater  curvature. 

Irregularities  of  outline. 

Inroads  of  growth  near  py- 
lorus: retention  of  food. 

^Esophageal  obstruction  at 
cardiac  orifice ;  no  evidence 
of  growth  of  stomach 

Light  areas  in  midst  of  bismuth 
shadow. 

Irregular  in  outline. 

Inroads  of  growth  giving 
hour-glass  appearance. 

Definite  irregularities  of  out- 
line. 

Stomach  normal ;  shadows 
well  seen  in  duodenum ; 
active  peristalsis. 

Irregular  in  outline. 

Large  atonic  stomach ;  nil 
else. 

Gastric  cavity  obliterated, 
except  along  greater  curva- 
ture. 

Obliteration  of  all  the  cavity, 
except  greater  curvature. 

Stomach  cavity  small  and 
irregular ;  back  pressure 
oesophageal  dilatation. 

Nil  abnormal  made  out. 

Irregularity  of  pyloric  portion. 
Cavity   nearly   obliterated. 
Cavity     nearly     obliterated ; 

right  side  diaphragm  pushed 

up. 
Irregularities    near    pylorus ; 

no  obstruction. 
Marked     inroad     of     pyloric 

portion ;   retained   food. 


Annular  growth  of  pylorus. 


Advanced  carcinoma;  inoper- 
able. 
Inoperable  carcinoma. 


Inoperable  carcinoma. 

Advanced   carcinoma. 

Carcinoma  of  pylorus  ;  gastro- 
jejunostomy. 

Post-mortem  six  weeks  later; 
growth  of  lesser  curvature 
5"X6";  cardiac  orifice  not 
involved. 

Inoperable  carcinoma ;  pos- 
terior wall  chiefly. 

Advanced  carcinoma. 

Inoperable  carcinoma. 

Mass  of  growth  in  lesser 
curvature. 

Plaque  of  growth  on  lesser 
curvature ;  duodenum  not 
explored. 

Growth  lesser  curvature. 

Operation  six  months  later ; 
large  mass  involving  an- 
terior wall. 

Post-mortem ;  massive  car- 
cinoma involving  whole 
stomach. 

Large  mass  extending  from 
lesser  curvature. 

Stomach  one  mass  of  growth. 


Growth  lesser  curvature,  size 

of    Tangerine. 
Post-mortem ;  carcinoma. 
Large   growth ;    inoperable. 
Growth   involving   colon   and 

stomach,  secondary  in  liver. 

Carcinoma  of  pylorus. 

Carcinoma  of  lesser  curvature 
and   pylorus 


Excised 
growth ; 
patient  died 
18  months 
later. 


No  contrac- 
tion of  car- 
diac orifice 
post-mortem. 
Patient  died 
3  months 
later. 


No  evid.  of 
growth  of 
stomach. 


Patient  died 
36  hours 
later,  cause 
unknown. 


Gastric  and  oesophageal  affections 


89 


Clinical 
No.  Abo.  Mux.  DjukiiohIh 


10  35  F.    Dyspepsia. 


20  52  M.    ?  Carcinoma. 


24  50  M.  Gastric  ulcer. 


29  54  M.    ?  Carcinoma  of 
stomach. 

31  55  F.     ?  Carcinoma  of 
stomach. 

41  32  F. 


Class  VI    (See  p.  36.) 
PYLORIC  OBSTRUCTION. 

X-ray  KintllngH.  >'lvc  Klri'linx*. 


Etoanrki 


Complete      atony;      bismuth  '  Pyloric    obftmotioil 


56  44  F.     ?  Gastric  ulcer. 

65  25  F.     ?  Gastric  ulcer. 

72  61  F.    Gastric  ulcer. 

80  46  M.    ?  Pyloric 

obstruction. 

88  47  F.    Carcinoma   of 
pylorus. 

94  32  M.  Dilat.  stomach. 

98  43  F.     ?  Gastric  ulcer. 


seen  in  stomach  for  5  days 

after  examination. 
Normal  stomach,  full  of  fluid  ; 

bismuth    in    stomach    after 

24  hours. 
Slight   delay    in    emptying. 


Marked  atony  ;  retained  rluid  ; 
slight   delay. 

Retained  food  ;  tone  perfect ; 
bismuth  retained  24  hours. 

Hour-glass,  partly  spasmodic ; 
peristalsis  of  upper  sac ; 
delayed  emptying  of  lower 
sac. 


Visceroptosis ;  delay  in 
emptying ;  marked  peri- 
stalsis. 

Some  delay  in  emptying,  in 
spite  of  excessive  peri- 
stalsis ;   some  visceroptosis. 

Extreme  atony  ;  marked  peri- 
stalsis ;  delayed  emptying 
(24  hours). 

Retained  food  ;  perfect  tone  : 
defective  peristalsis ;  de- 
layed emptying  (24  hours). 

Stomach  atonic  ;  marked  delay 
emptying  (24  hours). 

Definite  delay  in  emptying  (12 
hours)  ;  some  atony. 

Large  atonic  stomach  with  re- 
tained food  ;  slight  delay  in 
emptying ;  marked  peri- 
stalsis. 


(rial)  ;   gastro  j"juii';HU;my. 
Carcinoma   of   pylorus    with 

ulceration. 


Ulcer  of  leaser  curvature  and    Oared 

thickening       of       pylorus ;     ">ee  a'*° 
gastrojejunostomy 
Ulcer    surrounding    pylorus; 
gastrojejunostomy 


ind<T  Class 
IV. 


Extensive  carcinoma  involv- 
ing pylorus;  gastrojejunos- 
tomy 

Pyloric  thickening ;  no  ulcer 
of  body. 


Thickening  of  pylorus  ;  gastro- 
jejunostomy. 

Thickening     about     pylorus ; 
gastrojejunostomy 

Thickening     about     pylorus ; 
gastro- j  e  j  unostomy 

Large  mass  about  pylorus 


Growth  at  pylorus ;  huge 
stomach ;  gastrojejunos- 
tomy. 

Thickening  of  pylorus 


Patient 
cured. 

Not  cured ; 
patient  per- 
sisted in 
vomiting 
from  upper 
sac. 
Cured. 


Relieved  by 
operation. 

Cured. 


'  Cured '  2 
years  later. 

Cured. 


Adhesions  along  lesser  curva-    Cured, 
ture   and   pylorus :    ?  as  to 
obstruction. 


90 


Gastric  and  oesophageal  affections 


No.  Age.  Sex. 


Clinical 
Diagnosis 


X-ray  Findings. 


Operative  Findings. 


Remarks 


126  46  M.  Duodenal  ulcer. 

175  42  M.  Gastric  ulcer. 
179  34  F.  — 


192  51  M. 

201  48  M.    ?  Duod.    ulcer ; 
?  malignant. 

205  36  M.  Duodenal  ulcer. 


208  35  M.  Pyloric 

obstruction. 

217  36  F.    Carcinoma   of 
stomach. 

220  49  M.  Duodenal  ulcer. 


226  29  M.  Duodenal  ulcer. 

230  39  F.     ?  Pyloric 
stenosis. 


239  40  F.    Gastric  ulcer. 


250  49  M    Dilat.  stomach. 


269  40  F. 


272  43  M. 


?  Dilated 
stomach ;   py- 
loric stenosis. 

Duodenal  ulcer. 


293  35  F.    Dilat.  stomach. 


Nil,  except  rather  active 
peristalsis ;  stomach  empty- 
ing rapidly. 

Definite  delay  in  emptying; 
some   atony. 

Very  atonic  stomach ;  active 
peristalsis ;  slight  delay 
emptying. 

Retained  food;  delay  in 
emptying. 

Definite  delay  (24  hours)  ; 
stomach  normal ;  retained 
food  ;  peristalsis  not  active. 

Stomach  normal ;  violent  peri- 
stalsis occasionally ;  slight 
delayed  emptying  (10  hours). 

Retained  food  24  hours;  per- 
fect tone ;  peristalsis  absent. 

Huge  atonic  stomach ;  definite 
delay  in  emptying  (24 
hours). 

Stomach  normal ;  very  active 
peristalsis ;  occasionally 
some   delay  emptying. 

Stomach  toneless ;  definite 
delay  (24  hours). 

Hour-glass  stomach  and  de- 
finite delay  in  emptying 
lower  sac. 

Funnel-shaped  hour-glass ; 
inverted  peristalsis  in  lower 
sac;  delay  in  emptying  (24 
hours) . 

Huge  distended  stomach  full 
of  food;  marked  delay  (48 
hours). 

Complete  atony ;  delay  in 
emptying  (24  hours)  ;  in- 
complete hour-glass. 

Stomach,  normal,  but  occa- 
sionally active  peristalsis. 

Extreme  atony;  delay  empty- 
ing. 


9  months  later  pyloric  ob- 
struction found. 

Ulcer  of   pylorus ;    adhesions 

to   liver. 
Pyloric  thickening  and  ulcer ; 

stomach  very  large. 

Growth  about  pylorus  and 
liver. 

Cicatrix  of  pylorus ;  gastro- 
jejunostomy. 

Old  cicatrices  about  pylorus 
and  duodenum ;  gastro- 
jejunostomy. 

Ring     of     ulceration     round 

pylorus. 
Huge  stomach ;  growth  around 

pylorus. 

Adhesion     of     pylorus     and 

duodenum  to  gall-bladder; 

?  Pyloric  obstruction. 
Thickening    of    pylorus    and 

scarring  of  duodenum. 
Ring    of    ulceration    greater 

curvature   and   constriction 

of   pylorus. 

Multiple  scars  forming  tri- 
locular  stomach ;  growth  at 
pylorus. 

Large  growth  of  pylorus. 


Cicatrices  about       pylorus 
and  smaller  one  on  greater 
curvature. 

Adhesions  and  glands  malig- 
nant? about  pylorus. 

Growth    at   pylorus;    gastro- 
jejunostomy. 


Rapid  emptg. 
noted  in 
early  stage. 
Cured. 

Cured. 


Cured. 


Patient  died 
3  days  after 
operation ;  no 
cause  known. 
Cured. 


Cured. 


Cured. 


Patient  cured 
(6  months). 


Gastric  and  oesophageal  affections 


91 


OHnloal 
No.  A«o   Hex.        DlAgnoila. 


294  43  M.  Gastric,  ulcer. 


285  .r;0  M.   ?  Carcinoma  of 

stomach. 


309  56  M.   ?  hour-glass. 


313  34  M. 


320  37  M.  Gastric  ulcer. 


330  47  M.  Pyloric 

obstruction. 


335  39  F.     ?  Gastric  ulcer  ; 
?  carcinoma. 

338  40  M.  Dilat.  stomach. 

340  65  M.  Dilat.  stomach. 

342  42  M.  Dilat.  stomach  ; 
?  carcinoma. 


355  65  M.    ?  Gastric 

carcinoma ; 
?  gastric  ulcer. 

359  60  F.    Carcinoma   of 
stomach. 

370        M.  — 

373  49  F.    Pyloric 

obstruction. 

375  41  F.    Pyloric 

obstruction. 


X-rny  KlmlliiKH 


EU  BMfcl 


Slight        atony ;        occasional 
violent,  waves  of  peristalsis ; 

mi  marker]  delay  emptying. 

Definite  delay  in  emptying; 

occasion,!  I    violent    peristal 
sis;    inroads  of    growth    at 
pylorus. 

Rotaincrl   fluid  ;  perfei  t  tour  ; 
|>rn:;l;i,l:;i::     :  1 1  > . .  -  ■  1 1 1   ;     ilc  lioil  ■ 

delay    (24    hours). 
Retained        fluid ;        stomach 

normal ;       no      peristalsis ; 

delay  emptying  (24  hours). 
Rather      active      peristalsis ; 

some      atony ;      delay       in 

emptying. 


Retained  food ;  active  peri- 
stalsis, but  no  marked 
delay  in  emptying  (10 
hours). 

Hour-glass ;  secretion  into 
upper  sac ;  delay  in  empty- 
ing lower  sac  (24  hours). 

Atonic  stomach ;  delay  in 
emptying    (24   hours). 

Atonic  stomach ;  retained 
food ;  delay  emptying  (24 
hours). 

Retained  food ;  occasional 
active  peristalsis ;  inroad 
near  pylorus ;  slight  delay 
emptying. 

Delay  in  emptying  ;  irregulari- 
ties near  pylorus. 


Atonic      stomach ;      retained    Pyloric      thickening ; 
food ;   delay  in  emptying.  stomach. 


Thickening   pylorus;    gastro- 
jejunostomy. 

Growth  ahout  pylorus. 


Largo  growth  around  pyloruH  ; 
gasti  lorny 

Cicatrices;     stenosis    of    py- 
lorus. 

Mass  adherent  to  pylorus. 


Thickening    about    pylorus. 


Typical    hour-glass   stomach ; 

ulceration  and  cicatrization 

of  pylorus. 
Thickening  of  pylorus. 

Large  cicatrix. 


Inoperable  carcinoma  of   py- 
lorus. 


Pyloric  thickening ;  adhesions 
to   liver. 


Cored, 


huge 


large 


Retained   food ;   violent  peri-    Pyloric     obstruction 

stalsis ;  no  atony.  stomach. 

Atonic ;    delay    in    emptying    Carcinoma  of  pylorus  ;  gastro- 

(24  hours).  jejunostomy 

Atonic  ;  delay  in  emptying  (24  I  Pyloric    obstruction  :    gastro- 

hours).  jejunostomy. 


Btomach  th<; 

flabbiest 
surgeon  had 
handled. 


Secretion 
into  upper 
sac. 


Patient  died 
1  week  later. 
?  cause. 


92 


Gastric  and  oesophageal  affections 


No.  Age.  Sex. 


Clinical 
Diagnosis. 


X-ray  Findings. 


Operative  Findings. 


Remarks. 


383  59  M.  Abdom.  tumour 
399  33  M.  Gastralgia. 
410  63  M.  ? 


411  36  M. 
421  58  M. 


422  57  F. 
460  57  M. 

465  39  F. 

470  36  F. 
487  21  F. 
490  24  F. 


Gastroptosis. 
Duodenal  ulcer. 


Pyloric 

obstruction. 
Pyloric 

obstruction ; 

growth  ? 
Gastric  ulcer. 


Gastric  ulcer. 


Dilat.  stomach. 


Dilat.  stomach. 


Pyloric 

obstruction. 
Gastric  ulcer ; 

dilated 

stomach. 


531  42  M. 
573  18  F. 

580  43  F. 


Atonic  ;    delay    in    emptying ; 

no  inroads. 
Atonic  ;  retained  food  ;  slight 

delay  in  emptying  (6  hours) 
Retained        food ;        delayed 

emptying ;  tone  perfect. 
Delay  in  emptying  (10  hours). 
Irregularities    near    pylorus ; 

delay      in      emptying      (24 

hours)  ;  tone  fair. 
Irregularities ;        delay        in 

emptying   (24  hours). 
Delay  in  emptying  (6  days)  ; 

stomach  atonic. 

Incomplete  hour-glass ;  de- 
layed emptying  lower  sac. 

Atonic ;  slight  delay  in 
emptying ;  active  peristalsis. 

Delayed  emptying ;  atonic 
stomach ;  retained  food. 

Slight  delayed  emptying ; 
spasm  middle  stomach. 


492  31  F.    Neurosis. 

494  48  M.  Duodenal  ulcer. 

500  46  M.  Gastritis. 
512  47  F. 
523  42  F. 


?  Gastric  ulcer. 


Pyloric  obstruc- 
tion ;  dilated 
stomach. 


Hour-glass,  and  delayed 
emptying  lower  sac  (24 
hours). 

Stomach  displaced ;  retained 
food ;   delayed  emptying. 

Atonic ;  delayed  emptying 
(24  hours). 

Atonic ;  retained  food ;  de- 
layed emptying  (24  hours). 

Atonic  stomach ;  retained 
food ;  delayed  emptying. 

Atonic ;  retained  food ;  de- 
layed emptying  (24  hours). 

Hour-glass  (cicatricial)  ;  hy- 
persecretion to  upper  sac : 
delayed  emptying  of  lower 
sac. 

Atonic ;  retained  food ;  de- 
layed   emptying. 


Growth  of   pylorus. 

Large  ulcer  pylorus. 

Ulcer    pylorus;    gastro-jejun 

ostomy. 
Thickening   pylorus. 
Carcinoma  of  pylorus. 


Carcinoma  of  pylorus;  thin 
stomach  walls. 

Growth  of  pylorus  and  duo- 
denum. 

Pyloric  obstruction ;  old 
cicatrix ;  anterior  wall  of 
stomach. 

Pyloric  ulcer;  gastrojejun- 
ostomy. 

Growth  of  pylorus ;  gastro- 
jejunostomy. 

Large  stomach ;  cicatrix  near 
pylorus  and  also  ulcer  on 
greater  curvature ;  gastro- 
jejunostomy. 

Hour-glass ;  adhesion  to 
liver ;  pyloric  obstruction. 

Large  saddle-shaped  ulcer 
about  pylorus  ;  adhesions  to 
liver. 

Growth   of   pylorus. 

Thickening     about    pylorus ; 

gastro- jejunostomy 
Thickening     about    pylorus ; 

gastro  -  j  e  j  unostomy 

Stomach  very  large;  cicatrix 

about   pylorus. 
'  As  though  string  had  been 

tied   round  stomach  ' ;    also 

pyloric  ulcer. 


Cured. 


Thickening 
malignant. 


of        pylorus ; 


Hypersecre- 
tion with 
pyloric 
ulcer. 


Gastric  and  oesophageal  affections 


93 


Clinical 

No.  A({e    Sox.         OIukiiohIh. 


X-ray  Finding!. 


OpmtlTI  I  iri<llDK». 


BwuMfa 


582  29  M.                ? 

Delayed  emptying  (6  hours) ; 
itomach  atonic. 

1  bickening  of  pyloroe. 

583  54  M.  Abdom.  tumour 

Atonic ;     delayed     emptying 
(24    hours) ;    no   irregolarj 
tics. 

Carcinoma  ol  pylon 

584  42  F.    Pyloric 

Atonic;      delayed      emptying 

Post  mortem  ;   tfa  i  Icened   py 

obstruction. 

(24    hours). 

lonifl. 

585  43  M.  Duodenal  ulcer. 

detained     food  ;    .some     delay 

Thickened    pylorus;    gastro- 

in  emptying    (8   hours). 

jejunostomy. 

585a44  F.    Pyloric 

Stomach  normal ;  active  peri- 

Adhesions and  ci<  .itrix  about 

obstruction. 

stalsis  ;         hypersecretion ; 
slight   delay   in    emptying  ? 

pylorus  and  duodenum 

586a62  F.            — 

Atonic;     delay    in    emptying 
(24    hours). 

Carcinoma  of  pylorus. 

590  21  F.  Dilat.    stomach. 

Atonic  stomach ;  active  peri- 

Growth   at    pylorus ;    gastro- 

stalsis ;  excessive  secretion. 

jejunostomy. 

592  33  M.  Gastralgia. 

Atonic     stomach ;     delay     in 

Large      ulcer      at      pylorus ; 

emptying;   retained   food. 

stomach       large ;        gastro- 
jejunostomy. 

600  40  F.    Visceroptosis. 

Atonic ;  delay  in  emptying. 

Thickening   of   pylorus;    car- 
cinoma? 

687  60  M.    ?  Carcinoma  of 

Atonic ;    delay    in    emptying 

Cicatrix  of  pylorus. 

stomach. 

(24   hours)  ;    retained   food. 

682  27  M.  Pyloric  tumour. 

Tone  good ;   delay  in  empty- 
ing;    no     peristalsis;     ob- 
literation of  pylorus. 

Carcinoma  of  pylorus. 

752  40  M.    ?  Duod.  ulcer. 

Atonic ;     retained     food     (24 
hours). 

Ulcer  of  pylorus  ;  adhesions. 

753  25  M.  Gastric  ulcer. 

Atonic ;    retained    food ;    dis- 
placed     pyloric      portion ; 
active  peristalsis. 

Large  ulcer  pylorus. 

545  23  M.  Hodgkin's    dis- 

Stomach   normal ;    occasional 

Carcinoma  at  pylorus ;  many 

ease  ;     pyloric 

excessive  peristalsis ;  exces- 

secondary glands. 

obstruction. 

sive     secretion ;     gave     off 
little  C02. 

664  28  M.  Gastric  ulcer; 

Stomach    normal ;    occasional 

Large     growth      of      pyloric 

pyloric 

excessive     peristalsis ;     ex- 

region       and        secondary- 

obstruction. 

cessive  secretion ;   gave   off 
little  C02 ;  retained  food. 

glands. 

689  30  F.    Gastric  ulcer. 

Stomach      atonic ;       retained 

Pyloric   obstruction  marked  : 

Patient  was 

food;  delayed  emptying  (21 

old  ulcer. 

examined  2 

hours) . 

months  before 
and  very 
slight,  if  any, 
delayed 
emptying 
was  noted. 

94 


Gastric  and  oesophageal  affections 


Clinical 
No.  Age.  Sex.        Diagnosis. 


X-ray  Findings. 


Operative  Findings. 


Remarks. 


698  45  M. 

?  Carcinoma  of 
pylorus. 

Retained  food  ;  tone  perfect ; 
peristalsis  absent. 

Carcinoma  of  pylorus. 

713  32  M. 

Gastric  ulcer. 

Delayed      emptying ;      spasm 
middle. 

Ulcers  about  pylorus  and 
cicatrices. 

753b48  F. 

Carcinoma  of 

Retained       food ;        stomach 

Carcinoma   of    pylorus    fun- 

stomach  ? 

atonic ;    delayed    emptying 
(24   hours). 

gating  into  stomach. 

756  35  F. 

Old  gastro- 

Stoma    not    working ;     some 

No    gastrojejunostomy    had 

jejunostomy. 

delay  emptying ;  looks  like 
pyloric  obstruction 

ever  been  performed  ;  cica- 
trix of  pylorus ;  gastro- 
jejunostomy. 

764  47  F. 

Pyloric 

Retained    food ;    slight   delay 

Pyloric    obstruction ;    gastro- 

obstruction. 

emptying  (10  hours). 

jejunostomy. 

Gastric  and  oesophageal  affections 


95 


Clinical 
No.  Ago.  Sex.         Diagnosis, 


Class  VII.    (See  p.  50). 
ADHESIONS. 

X-ray  findings.  Operative  findings. 


Kf-mark*. 


151  38  F.    Neurasthenia. 

Stomach    atonic;    held    down 

Old  appendix  ;    adhesions   of 

Not  cured 

to      colon      by     adhesions; 

colon. 

1  9  mo-,  later 

transverse    colon    fixed    in 

iiiu'h  better. 

pelvis. 

251  10  M.  T.B.  peritonitis 

liilocular   stomach ;    food    re- 

Tuberculosis;         peritonitis; 

Relieved. 

tained   in  many  pockets  of 

multiple  adhesions. 

small  intestines. 

408  61  F.    Gastric  ulcer. 

Bands  divided   stomach,   and 

Multiple  adhesions  ;  old  ulcer 

as  in  Case  251. 

below  cardiac  orifice. 

472  60  M.  Old    perforated 

Adhesions  to  liver,  etc. 

Adhesions  anterior  wall   and 

duodenal  ulcer. 

liver. 

479  42  F.    Old  strangu- 

Stomach     bound      down      in 

Adhesions     small     intestine, 

lated  hernia; 

pelvis. 

stomach  and  colon. 

?  adhesions. 

591  28  M.  Dyspepsia. 

Nil,      except     stomach     dis- 

Appendix adhesions  on  right 

Long  appendix 

placed  to  right. 

side ;   stomach  normal. 

fixed  up 
towards 
right  hypo- 
chondrial 
region. 

699  56  M.    ?  Carcinoma  of 

Stomach    cavity    represented 

Mass  of  adhesions  stomach  to 

stomach   or 

by    3     sacs,     very     small, 

liver ;     anterior     gastroje- 

oesophagus. 

bound  to  liver;  back  pres- 
sure      oesophageal     dilata- 
tion. 

junostomy. 

H 


96 


Gastric  and  oesophageal  affections 


Xo.  Age.  Sex. 


Clinical 
Diagnosis. 


Class  VIII.     (See  p.  50.) 
POST   OPERATIVE. 


X-ray  Findings. 


10  35  F. 

19  55  F. 

26  19  F. 
35  32  F. 

41  32  F. 


Old  gastroje- 
junostomy (see 
Class  VI.). 

Pyloroplasty. 


Perforated 
gastric  ulcer. 

Old  gastroje- 
junostomy (see 
Class  IV.). 

(See  Class  VI.) 


44  25  F. 

Gastro- 

jejunostomy. 

206  23  F. 

Old  gastro- 

jejunostomy. 

207  30  F. 

Old   gastro- 

jejunostomy 

1908. 

209  31  F. 

Old     gastroje- 

junostomy for 

hour-glass. 

257  49  F. 

Old   gastro- 

jejunostomy. 

263  41  F. 

5    weeks    after 

gastrojejunos- 

tomy. 

266  43  M. 

Old   gastro- 

jejunostomy. 

357  52  F. 


Old  gastroje- 
junostomy to 
upper  sac  of 
hour-glass. 


Xo  increase  in  tone ;  food 
still  delayed  in  stomach 
longer  than   24   hours. 

Hour-glass  condition  :  no  ob- 
struction, stoma  working 
perfectly. 

Food  through  stoma  quite 
freely. 

Stoma  working  perfectly. 


Hour-glass  marked,  but  stoma 
works  perfectly  when  food 
reaches  it. 


Obstruction  in  duodenum. 


Stoma  working  perfectly. 


Gastrojejunostomy  working 
perfectly ;  marked  spasm 
middle  of  stomach  forming 
hour-glass. 

Stoma  from  upper  sac  work- 
ing perfectly,  but  food  re- 
tained in  lower  sac  24 
hours  after. 

Adhesions  forming  hour- 
glass ;  stoma  working  per- 
fectly. 

Stoma  working  perfectly. 


Hour-glass  stomach ;  well- 
marked  ;  stoma  working 
perfectly. 


Delayed  emptying  of  lower 
sac ;  stoma  from  upper  sac 
works  well. 


Operative  Findings. 

Remarks. 



Patient 



unrelieved 

Nil    found    to    account 

for 

Patient  per- 

hour-glass. 


Adhesions. 


Marked  cicatrix  above  stoma; 
gastro-gastrostomy. 


Well-marked  pyloric  obstruc- 
tion ;   lower  sac  excised. 


Adhesions  broken  down. 


Hour-glass,  with  active  ulcer. 


sisted  in 
vomiting 
from  upper 
sac. 


Patient  spoken 
to  severely 
and  completely 
cured. 
Unrelieved. 


Patient  cured. 


Cured. 


Thickening  of  pylorus ;  lower 
sac  excised. 


Cured   by 
gastroplasty , 
a  small  ulcer 
of  body  had 
been  noted  at 
time  of  first 
operation. 
Cured. 


Gastric  and  oesophageal  affections 


97 


OUnioal 

No.  Ako.   Sox.         DIiikikihIh. 

363  41  F. 

Old  gastro- 

jejunostomy, 

398  38  P. 

— 

416  47  M. 

Old  gastro- 

jejunostomy. 

41!)  22  F. 

Old    gastro  je 

junostomy     '2 

months    after 

operation. 

X-ray  Pindlngl. 


Opmtlrt  i  indinK*. 


Spasmodic    hour-glass;    stoma 
working  perfectly. 

Sour  glass ;  marked  vomiting 

from    upper  :iac. 


Nil     found     to     jircount     for     f'nr< 

boor  k'I;i««- 
Nothing  to  account  for  tie- 
liour  glass ;    appendix     n 
moved. 
Adhesions  about  jejunum  and    Many  adhesions 

stomach. 


Stoma  working  perfectly,  hut 

placed   far  from  pylorus, 


Growth  of  pylorus;  adherenl 
to     g,-ill  bladder ; 
excised. 


treeks 

.'in. 


470  36  F. 

171  30  F. 
183  30  M. 
524  46  F. 

539  35  M. 

»63  36  F. 
•30  47  M. 
■94  45  M. 

'09  50  F. 
189  30  F. 

56  35  F. 

57  34  M. 


3    weeks    after 
gastro- 
jejunostomy. 

Gastro- 
jejunostomy. 

Old   gastro- 
jejunostomy. 

Gastrojejunos- 
tomy 5  years 
ago. 

Old  gastro- 
jejunostomy 

1  year  after 
operation. 

Old  gastro- 
jejunostomy 

2  years  ago. 
Old  gastro- 
jejunostomy 
10  months. 

Old    gastro- 
jejunostomy ; 
duodenal 
obstruction. 

Gastrojejunos- 
tomy 2  years. 

Gastrojejunos- 
tomy 6  weeks 

after  operation 

Old  gastro- 
jejunostomy. 


Old   gastro- 
jejunostomy. 


Jejunum  kinked  behind 
stomach. 

Stoma  not   patent. 

Kink  6  inches  from  stoma. 

Stomach  atonic ;  excessive 
peristalsis  ;  stoma  not  work- 
ing ;  obstruction  at  duodeno. 
jejunal   flexure. 

Food  passing  freely  both 
ways  ;  excessive  peristalsis  ; 
stoma  5  inches  from  py- 
lorus. 

Stoma  working  perfectly. 

Adhesions  blocking  jejunum. 


Stoma     working      perfectly ; 
hypersecretion. 


Both      stoma      and      pylorus 

patent. 
Stoma    not    working ;    looks 

like   pyloric   obstruction. 

Stoma    not    working ;    slight 


Jejunum  stitched  up. 


Adhesions. 

Adhesions    with    kinking    of 

jejunum. 
Cicatrization     about     stoma 

jejunum,  and    adhesions. 


The  pa 

due  to  '  ■ 

OS    of 

the  «t' 

on  the  food 

in  the  pyloric 

port  ion  ;  re- 
lieved   by 
operation. 
Cured. 


Many  adhesions  dissected  out.  |  Patient  died 


Adhesions  anterior  wall. 


Cured. 


delay  emptying. 


Stoma    working    well ;    slight 
obstruction  in  jejunum. 


No    gastrojejunostomy    had    Cured, 
been    performed ;     cicatrix 
of  pylorus. 

No  gastrojejunostomy  had 
been  performed ;  cicatrix 
of  pylorus  :  gastrojejunos- 
tomy. 


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Ind 


ex 


Index 


Adhesions,  50. 
Aerophagy,  40- 
Air,  injection  of,  1 1. 
Anaesthetics,  action  <>n  stoma*  h,  ,  • 
Appendicitis,  66. 

with  aerophagy,  50. 
Appendix  dyspepsia,  70. 

Bougies,  13,  16. 

Capsules,  gelatine,  10. 

gold-beater  skin,  1 1 . 
"Caput  duodeni,"  5S. 

Carcinoma  of  stomach,  46. 
Constipation,  65,  75. 

Dermatitis,  6. 
Drugs,  11. 

alcohol,  11. 

belladonna,  11,  15,  41. 
—  bicarbonate  of  soda,  11,  26,  37. 

valerian,  11. 

Duodenal  irritation,  notes  on  cases, 

55- 

-  peristalsis  in,  56. 
-  ulcer,  54. 
Duodenum,  food  seen  in,  57. 

second  sphincter  in,  5S. 

segmentation  of  food  in,  69. 

Dysphagia,  17. 

Euteroptosis,  32. 

Foods,  g,  17,  26. 

Free  acid  in  stomach,  12. 

Fundamental  principles,  5. 

Gastric  ulcer,  39. 

aetiology,  62. 

notes  on  cases,  43. 

Gastrojejunostomy,    examinations 

after,  52. 
Gastroptosis,  32. 
Gravity,  action  of,  56. 

Hour-glass  stomach,  39,  44. 
Hypersecretion,  26,  37,  66. 

Inflation  of  stomach,  11. 


I  I    I  11  II  II  I  I  I  ,      I  I  1 1   <    I      |  , J  _ 

aftei  gai  tro  enti  i"  tomy, 

I       ige,  to,  2$,  4"- 
Method  "f  •  saminaf  ion,  gi  m  ral,  1 

<>[  oe  lophagu  ,  1 

Mucou  1 1  "lit i  , 

Normal  stomach,  22. 

operation  in,  29. 

(Esophageal  obstruction,  13. 
pouch,  19. 

(Fsophagoscope,  14. 
(EsophagUS,  dilatation,   19. 
foreign  bodies,  16. 

peptic  ulcer,  20. 

power  of  recovery,  21. 

spasm  of,  15. 

Penetrating  ulcers,  41. 
Peristalsis,  absence  of,  28. 

in  carcinoma,  47. 

— —  in  duodenal  irritation,  56. 

nervous  control,  27. 

— —  in  pyloric  obstruction,  34. 
Position  of  patient,  7. 
Post-operative  examinations,  50. 
Preparation  of  patient,  S. 
Protection  from  rays,  6. 
Pyloric  obstruction,  33. 

notes  on  cases,  36. 

peristalsis  in,  34. 

— retention  of  food  in.  35. 

ulcer,  diagnosis,  38. 

notes  on,  37. 

Pylorus,  carcinoma,  35. 

control  of,  26. 

Results  after  operation, 

vSeptic  conditions,  69. 
vShadow,  clear  spaces  in,  48. 

pyloric,  S. 

Small  intestine,  54. 

Soft  rays,  6. 

Spasmodic  contraction,  47. 


126 


Index 


Stomach.,  adhesions,  50. 

-  anatomy,  22. 

atony,  30. 

carcinoma,  46. 

-  displacement,  29. 

— —  honr-glass  contraction,  39. 

-  hypersecretion,  26,  37. 
incidence  of  lesions,  53. 

-  inflation,  11. 

-  nervous  control,  24. 

normal,  22. 

peristalsis  in,  25,  27. 

physiology,  22. 

rapid  emptying,  26,  56. 


vStomach  (continued), 

retention  of  food  in,  36. 

reverse  peristalsis  in,  25. 

shape,  23. 

— -  spasm,  29,  39,  44,  62,  64. 
-  tone,  24,  27,  35. 

Tabulation  of  cases,  77. 
Teeth,  carious,  64,  75. 

Upright  position,  5. 

Visceroptosis,  31. 
Vicious  circle,  51 


hhPHHH 


